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Wiki Auditor question about 4x4 method for PE

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lrosselli

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Pennsylvania Medicare auditors score a physical exam as Detailed when there are 4 or more exam items noted in the medical record for 4 or more body areas or organ systems. They use the 1995 E/M examination guidelines utilizing this 4x4 tool. Do you think the following is sufficient documentation for Detailed PE (4x4 method) or should there be more details?:
"She is awake, alert and oriented. Lungs are clear. Heart exam reveals regular rate and rhythm. Abdomen is soft and protuberant with hypoactive bowel sounds, significant tenderness in the upper abdomen without rebound."

Thank you!
 
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