Wiki Opinion on Exam Level

[ckelder]

I was just wanting to get some other coder's opinions on this exam, as to what level they would choose.

CC: Follow up of psych issues.

Exam:

General: well developed, well nourished, in NAD
Head: normocephalic and atraumatic
Lungs: clear bilaterally to auscultation
Neurologic: speech clear/appropriate, alert and oriented to person/place and time
Psych: Alert, calm but perserverating over mafie and events that she states happened to her mother in the 1940's

I came up with this being expanded focused exam but since I am new to coding I would like to get some other opinions.
Thanks in advance.

 

[MnTwins29]

Agree with EPF

While you have 5 areas/systems (if you include constitutional), none of them are examined in detail with this documentation, so I would use EPF (using 1995 guidelines, as that is what our practices use).

However, with 1997 guidelines, they are not so helpful with the head documentation, nor does any of the documenation for neurological apply to that system - those are psychiatric findings. WIth only 4 bullets that I counted this would be PF.

When comparing the two sets, use the one that is more beneficial to the physician. So even if I throw out neurological in my 1995 analysis and place that under psych, I stll get EPF for 1995 so that is what I would use.

Interesting case - would like to hear others.

 

[kcrouse]

EPF VS. Detailed

I have a very simple question about the 4x4 rule. If you were counting the elements in the respiratory organ system and the provider documents clear to auscultation, no rales,and no rhonchi, how would you count the number of elements? The reason I ask is because I am working on building a new coding department and I am trying to find some examples on how to explain the elements. Would you recommend using the bullets in the 97 guidelines but I would only need 4 or would you use the above items and count them out? Please help me explain the 4x4 rule a little better.

 

[LLovett]

I agree with EPF for that exam. Lance is right for the general multisystem exam, what they have listed as neuro is actually psych. I disagree on the head comment though, under 97 you get credit for that statement under MS. It doesn't make a difference in this case though. Just to throw a bit of a curve though, it depends on which exam you are using where some of these elements fall. It is interesting that only a few of the 97 exams actually separate Neuro and Psych, most lump them together.

I have been doing this since 1999 and I have never heard of a 4x4 rule. No clue what that means but the "elements" you have listed for respiratory under 97 only support 1 bullet, auscultation.

Laura, CPC, CPMA, CEMC

 

[MnTwins29]

Laura, thanks

Thanks for the info on the head exam element. While this makes sense for MS, just reading "atraumatic" makes me wonder if they mean MS, neuro, or something else. Also, and this may not be correct, but it was drilled into me from early in my coding days, is that "normocephalic" isn't helpful for exam bullets. Mainly the same reason - okay, the neck is fine but what were you examining - ROM, pain, etc?

 

[kcrouse]

Question

I agree with EPF for that exam. Lance is right for the general multisystem exam, what they have listed as neuro is actually psych. I disagree on the head comment though, under 97 you get credit for that statement under MS. It doesn't make a difference in this case though. Just to throw a bit of a curve though, it depends on which exam you are using where some of these elements fall. It is interesting that only a few of the 97 exams actually separate Neuro and Psych, most lump them together.

I have been doing this since 1999 and I have never heard of a 4x4 rule. No clue what that means but the "elements" you have listed for respiratory under 97 only support 1 bullet, auscultation.

Laura, CPC, CPMA, CEMC

The exam I am using is from the 95 guidelines. Could you please help me explain how to use the elements in the 95 guidelines to determine if you have an EPF or detailed exam?