Wiki Exam

[KaylaRieken]

GENERAL: Alert and pleasant female who appears in no acute distress.
SKIN: No rash or lesions
NEUROLOGIC: Exam is grossly intact.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neck: Supple
RESPIRATORY: Breathing is unlabored.
EXTREMETIES: She moves all extremities without difficulty.


How many organ systems are here for a 95?

 

[Chelle-Lynn]

For organ systems based on 95 guidelines I come up with the following:

Eye = Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neuro = Exam is grossly intact
Repira = Breathing is unlabored
Musco = Head is normocephalic, atraumatic.Neck: Supple. She moves all extremities without difficulty
Skin = No rash or lesions
Psych = Alert and pleasant female who appears in no acute distress.

Note, some will see the psych as constitutional...it is one of those either/or....however in the case the total would still be 6 systems.

 

[KaylaRieken]

Thank you. So this would not be enough for a 99204 with the 95 or the 97 guidelines?

 

[Chelle-Lynn]

For the exam section it would level to a 99203