jmcalhaney
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I was wondering if I could get an opinion on what level of exam you think this might be:
Wt: 195 lbs. Gen: NAD. HEENT: NC/AT, EOMI, PERLA, No scleral icterus. Throat clear. CV: S1 and S2 w/o murmur, rub, or gallop. Chest: clear to ausculation and percussion. There is no spider telangiectasia. ABD: Normoactive bowel sounds, soft, nontender. No hepatosplenomegaly, no rebound. There is no ascites. BACK: Nontender RECTAL: Deferred. Neuro: Alert and oriented x 3, nonfocal. Extremities: There is no cyanosis, clubbing, or edema.
I have found that for the 95 guidelines, the physician examined Constitutional, HEENT (counted as 1), Respiratory, Cardio, GI, Neuro, and Musculoskeletal. The physician has coded this as a comprehensive exam and each one of his exams is almost identical to this note. This results in him coding for a comprehensive each time and I think that he may be overcoding as a result of this. Any opinions are appreciated. Thanks.
Wt: 195 lbs. Gen: NAD. HEENT: NC/AT, EOMI, PERLA, No scleral icterus. Throat clear. CV: S1 and S2 w/o murmur, rub, or gallop. Chest: clear to ausculation and percussion. There is no spider telangiectasia. ABD: Normoactive bowel sounds, soft, nontender. No hepatosplenomegaly, no rebound. There is no ascites. BACK: Nontender RECTAL: Deferred. Neuro: Alert and oriented x 3, nonfocal. Extremities: There is no cyanosis, clubbing, or edema.
I have found that for the 95 guidelines, the physician examined Constitutional, HEENT (counted as 1), Respiratory, Cardio, GI, Neuro, and Musculoskeletal. The physician has coded this as a comprehensive exam and each one of his exams is almost identical to this note. This results in him coding for a comprehensive each time and I think that he may be overcoding as a result of this. Any opinions are appreciated. Thanks.