Comprehensive Exam?

clbarry8033

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I was just wondering if you guys would count this as a comprehensive exam in 95 guidelines.

Vital signs: Stable. He is afebrile.
Cardiovascular: Reveals good respiratory effort. Pulses are regular.
Extremities: No cyanosis, clubbing, or edema. No calf tenderness.
General: He is alert and oriented x3. No apparent distress.
HEENT: Pupils are equally round and reactive to light. Nares are patent.
Neck: Trachea is midline.

Thanks!
 

thomas7331

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95 guidelines require findings in at least 8 organ systems to qualify as a comprehensive exam. I really don't see that here.

I could understand counting it as detailed (constitutional, respiratory, cardiovascular, eyes, ENT; or body areas head, neck, chest and extremities). I know some very creative auditors who might find 8 systems in here, but I think that defies common sense; it's over-reaching and a misuse of the guidelines. To consider this a comprehensive exam would undervalue the providers who actually do perform and document complete multi-system exams, and it would make the definition of comprehensive pretty meaningless.
 

clbarry8033

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I was thinking there were 8. Aren't we supposed to put exam elements into their own organ system?

Constitutional: Vitals
Cardiovascular: Pulses
Respiratory: Respiratory effort
GI: RUQ pain to palpation
Musculoskeletal: Extremities
Psych: A&O x3
Eyes: Pupils equal
ENT: Nares are patent/trachea is midline

Let me know what you think.

Thanks again for your input.
 

clbarry8033

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Whoops! I didn't put the abdominal part of the exam in there.

Abdomen: Soft. RUQ pain to palpation.

Are there 8 now?
 

thomas7331

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I would not count the extremities as musculoskeletal - the findings reported there are all related to the cardiovascular system.

I personally do not like to count 'alert and oriented x3' as psychiatric, although many providers have argued with me on this. I do think it's clinically important information, but I consider it part of constitutional/general appearance, unless the patient is specifically being evaluated for potentially psychiatric issues. Some people would even argue that edema is can be counted as lymphatic too.

Best is to look at this in the context of the whole note and code. What I've found in looking at how payers audit notes is that the nature of the presenting problem and the MDM carries a lot more weight than the history or exam. If those two things support your level, payers aren't going to split hairs over whether an exam like this is detailed or comprehensive.
 

thomas7331

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Calf tenderness is usually an indication of DVT or claudication, both of which are cardiovascular, especially in the context of the provider assessing for edema, pulses and clubbing. For musculoskeletal, I'd expect to see things like range of motion, alignment, assessment of bones and joints, muscle strength and tone, gait and station. Like I said above, I'd consider this a detailed exam because that's where I think it fits in the spectrum of exams that are commonly documented, but it all depends on how you decide to count. Unfortunately, beyond the guidelines, there aren't any standards set for this kind of thing and a lot of it is subjective. Which is why the more important thing is consider how the provider's narrative of the patient's problem fits with the level you choose.
 

clbarry8033

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Thank you for your time and your opinion. It's good to know that even the exam can be subjective.
 
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