Wiki Urgent!!!!!Physical examination points

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NishaJ

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Hi guys..I need a help to count the Physical examination .
I have a doubt whether this can be coded based on 95 guideline or 97 guideline. I need an assistance.

Physical Examination.
General:
Build obese. General appearance happy, no acute distress, alert and oriented to person, place and time, pleasant, well hydrated, well nourished. LMP 03/11/2017-post.
Skin Eruption:
Site scalp. Distribution Localized. Description SebDerm- Erythematous, scaly patches noted. Scale appears loosely adhered and greasy. Condition status Patient with moderate improvement .
Skin Eruption-Additional:
Site bilateral arms and legs, trunk. Distribution Scattered. Description Xerosis- Diffuse and scattered skin involvement with barely visible scaling roughness of skin. There are diffuse excoriations noted secondary to the associated pruritis. There are areas of fine scales and hyperkeratosis observed sparing the flexural folds. Slight fissuring is noted. Condition status Patient with moderate improvement noted.
 
Because 1997 exam lists skin exam as:

Skin Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremitiesInspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:Head, including the face andNeckChest, including breasts and axillaeAbdomenGenitalia, groin, buttocksBackRight upper extremityLeft upper extremityRight lower extremityLeft upper extremityNOTE: For the comprehensive level, the examination of at least eight anatomicareas must be performed and documented. For the three lower levels ofexamination, each body area is counted separately. For example, inspectionand/or palpation of the skin and subcutaneous tissue of the right upper extremityand the left upper extremity constitutes two elements.Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis

I'd consider this expanded problem focused.
 
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