Wiki Problem Focused vs Detailed 95 guidelines

[AR2728]

So-I know this exam does not meet detailed using 97 guidelines, but can this be considered detailed using 95?

This format is typically what I see from our Ortho on new patient visits:

Presented with shoulder pain

BP and Pulse documented
Exam
In general, alert an oriented times thress, in no apparent, distress, well nourished, well developed male.
Skin is intact throughout the right upper extremity. All compartments soft. No open wounds.
Vascular: 2+radial pulse
Nero: Sensation intact to light touch c5-t1. Motor intact 5/5 strength c5-t1
Musc: Minimal tenderness to palp. along the right AC joint. No pain on cross arm adduction. Forward flesion 180 degrees, external rotation 50 degrees, internal rotation to L1. Positive Hawkins, positive near. Right shoulder negative o'brien's, negative speeds test. Negative apprehension. Negative belly press test. Negative drop arm test.

I would really appreciate a rational for answer so that I can better determine future levels.

Thanks!

 

[btadlock1]

So-I know this exam does not meet detailed using 97 guidelines, but can this be considered detailed using 95?

This format is typically what I see from our Ortho on new patient visits:

Presented with shoulder pain

BP and Pulse documented
Exam
In general, alert an oriented times thress, in no apparent, distress, well nourished, well developed male.
Skin is intact throughout the right upper extremity. All compartments soft. No open wounds.
Vascular: 2+radial pulse
Nero: Sensation intact to light touch c5-t1. Motor intact 5/5 strength c5-t1
Musc: Minimal tenderness to palp. along the right AC joint. No pain on cross arm adduction. Forward flesion 180 degrees, external rotation 50 degrees, internal rotation to L1. Positive Hawkins, positive near. Right shoulder negative o'brien's, negative speeds test. Negative apprehension. Negative belly press test. Negative drop arm test.

I would really appreciate a rational for answer so that I can better determine future levels.

Thanks!

Under 1995 guidelines, I think you've got a pretty solid detailed exam - you only need 2-7 areas, and you've got 5. I'm not really familiar with the tests you mentioned, but I imagine that if I looked them up, I'd find that they probably correspond with bullets from the 1997 guidelines, also. You may not have enough to have a detailed exam under 1997, but I bet you're closer than you think. Try looking at the Single Organ System exam requirements for Musculoskeletal, and see if you can meet more criteria there. Hope that helps!