Wiki Level 5 exam

[NESmith]

Would someone be able to tell me if you think this qualifies for a level 5 exam for Ortho?

Vitals:
BP-Sitting
Pulse Rate-Sitting
Height
Weight
Body Mass Index
Body Surface Area

Physical Examination: On physical exam today, the patient is a pleasant gentleman accompanied by his wife.
Musculoskeletal:On inspection of the cervical spine, skin is intact with no sign of infection around his incision site. He has a slight sway with Romberg test and unsteady tandem gait. Testin of the upper extremities dermatomes and myotomes show intact sensation; 5/5 strenghth bilaterally.Peripheral pulses are palpable. Reflexes are symmetric. He has no pathologic reflexes. Skin: No lesions. Neurological: No faocal motor or sensory deficit. Coordination is intact, oriented x 3 . Reflexes are normal. Cardiovascular: No edema or varicosities. Peripheral pulses + 2/4 bilaterally throughtout.

Thank You for your help.

 

[mitchellde]

Is this a follow up encounter? Is this the entire note? There is no CC there is no MDM so no this cannot be a level 5, and if it is post op then it is part of global.

 

[NESmith]

No, this is not a follow up but a new which he is billing an established level five because one of other Ortho docs referred to this provider because he specializes in Spine. I did not include the whole note, sorry. There was a CC and HPI which was a comprehensive and the MDM was Moderate. Would you like to see the whole note? Thanks

 

[MikeEnos]

So what you're asking is: does this qualify as an comprehensive physical exam? The answer is no.

As you know, there are 2 exam guidelines, '95 and '97 and you can give credit to whatever is more advantageous. Here's how this exam scores by '95 guidelines:

Physical Examination: On physical exam today, the patient is a pleasant gentleman accompanied by his wife.
Musculoskeletal:On inspection of the cervical spine, skin is intact with no sign of infection around his incision site. He has a slight sway with Romberg test and unsteady tandem gait. Testin of the upper extremities dermatomes and myotomes show intact sensation; 5/5 strenghth bilaterally.Peripheral pulses are palpable. Reflexes are symmetric. He has no pathologic reflexes. Skin: No lesions. Neurological: No faocal motor or sensory deficit. Coordination is intact, oriented x 3 . Reflexes are normal. Cardiovascular: No edema or varicosities. Peripheral pulses + 2/4 bilaterally throughtout.

1. Constitutional
2. Musculoskeletal
3. Neurologic
4. Cardiovascular
5. Integumentary

You could also argue that the provider documented the mood as being pleasant, which is a psychological finding. That would make 6. That's enough for detailed for most regions (check with your local carrier.)

Going by '97 guidelines, I'm not even going to bother because it's not going to be higher than Detailed. To get credit for a comprehensive musculature exam using '97 guidelines you would need to have an assessment of their general appearance. Since that's missing, it can't possibly be Comprehensive.