'95 vs '97 Guidelines for this exam


Columbus, OH
Best answers
I am looking for help comparing the score for this physical exam using the 1995 Guidelines versus the 1997 Musculoskeletal Exam ones. I prefer the '97 Guidelines because they are more "black & white" but my orthopedic providers have difficulty "scoring well" and so we are auditing using both as a test. I would love your feedback.

Physical Examination: Pleasant, age appropriate 48-year-old female, alert and oriented x3. Left shoulder shows no cutaneous abnormalities. Radial, medial, and ulnar nerves intact to motor and sensory exam distally. She can forward elevate, with the pain mostly horizontal. With rotator cuff testing, she has pain with some weakness. She has some periscapualr pain. With the range of motion of her neck she does describe that it does cause some pain in her shoulder as well. She reports some of the pain is reproduced with motion of her neck.

1995 = Expanded problem-focused or detailed exam level?
I count 5 organ systems: constitutional, msk, neuro, skin and psych. Unless you are coding for a payer who follows the "4x4" rule for exams and wants to see 4 elements documented in 4 organ systems, I would count this as a detailed exam under 1995. The guidelines state a detailed exam is an extended exam of affected areas and other symptomaic or related organ systems, and the documentation supports a detailed exam of this patient's shoulder.