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AprilSueMadison

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We use 1997 guidelines first of all.

This is an example of what I see:
Physical Exam:

Constitutional:
No acute distress. Well nourished.

Integumentary:
The following areas were examined by inspection and/or palpation and found to be normal except as noted in the significant findings below: head / face, neck, chest, abdomen, back, left upper extremity, right upper extremity, scalp / hair and eccrine / apocrine glands.

Exam Description
L axilla and R axilla: flesh colored pedunculated papules.
L and R axilla: erythematous sharply demarcated patches with peripheral scale.
L shoulder: multiple brown plaques

Psychiatric:
The patient is oriented to time, place, person, and situation
Click to expand...
.

Can someone please help me determine the level of exam? Then could you explain WHY it is that level to me so I understand it better?

I'm having a hard time figuring this portion of the e/m coding out. Thank you!
 
Do you use the General Multi-System Exam or the Single Organ System Exam? This looks like a Dermatology exam and there is a Single Organ System Exam for skin. CMS has a guide to E/M services. http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf Maybe this will help you.

Under the Genreal Multi-System Exam this would come out to problem focused (four bullets genreal appearance, psych, and two for skin)

Under the Skin Exam this would be Expanded Problum Focused (10 bullets)
 
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I have portions of that book printed out, and primarily I try to use this...

http://emuniversity.com/PDF/Specialty_Exam_Dermatology.pdf

The catch is...I'm not 100% sure how to count on this. When I count the above, I get 11 bullets.

Constitutional
Psychiatric
head / face,
neck
chest
abdomen
back
left upper extremity
right upper extremity
scalp / hair
eccrine / apocrine glands

I'm also coming up with Expanded Problem Focused, but I feel like I still don't have a good understanding of how to count.
 
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