Wiki Exam help

[KaylaRieken]

Doctor documents this in the physical exam:

PE: She is alert and pleasant and in no acute distress. She is very hard of hearing and interacts little during the exam. Most
history is provided by her daughter. She is 5’6, 150# sitting comfortably in a wheelchair.
RESPIRATIONS: Deep and unlabored.
NEUROLOGIC: Exam is nonfocal.
SKIN: Visible skin is without rash or lesion.
Axilla and groins are negative for adenopathy or hernia.
EXTREMITIES: No deformities.

I can count constitutional, respiratory, neurological, skin, lymphatic, musculoskeletal. Could I count hard of hearing as ears? Also could I count alert as psychiatric?

 

[kdlberg]

ENT does list hearing as part of a multi system exam. "Alert" might be pushing it a bit on the psychiatric; on the other hand, "interacting very little" combined with alert could describe the mood/affect.

So that would make 8 systems, which is considered a comprehensive exam.

My question would be, what is the medical necessity of a comprehensive exam? Does it fit with the nature of the chief complaint(s) and/or the patient's chronic medical conditions? Otherwise, that's counting systems just to count them, and you run the risk of overcoding.

 

[KaylaRieken]

This is for a new patient exam. Patient has kidney stones, kidney cysts, hydronephrosis, and uti.

Thank you for replying.