Wiki Comprehensive Examination????

[rossirob001]

What level of exam do you code this to? How many organ systems??

BP is 130/80, pulse 67, in no acute distress. She is alert, awake and oriented x3. No cyanosis, jaundice or JVD. Thyroid is central and not enlarged. No carotid bruits. Lung fields are clear to auscultation. Heart is regular in rate and rhythm. Abdomen has positive, nontender, and nondistended. Extremities reveal no edema. Neurological exam in grossly nonfocal. Her device is located in the left side and her incision is well healed.
--Provider stating it is COMPREHENSIVE EXAM, and I'm just not seeing it!! How do I explain to provider????? Suggestions????

 

[sparkles1077]

I see comprehensive:

constitutional
enmt - thyroid exam
psych - alert and orient x 3
cardio
resp
gi
skin
neuro

 

[a.montaruli@gmail.com]

I do not see a comprehensive exam here. This is an expanded problem focused exam. The organ systems/ body parts are:

Psych
Integumentary
Thyroid body area
Respiratory
Cardio
Abdomen body area (not enough info to be GI)
Neuro

Constitutional requires 3 vital signs and only 2 are listed (no credit)
5 organ systems
2 body areas
No detail

This exam is expanded problem focused.

Hope this helps,
Andrew

 

[OCD_coder]

Using 1995 Guidelines: Detailed (7 organ systems)
Constitutional: BP is 130/80, pulse 67, in no acute distress.
Psych: She is alert, awake and oriented x3.
Integumentary: No cyanosis, jaundice
Her device is located in the left side and her incision is well healed.
CV: No carotid bruits. JVD. Extremities reveal no edema. Heart is regular in rate and rhythm.
Respiratory: Lung fields are clear to auscultation.
GI: Abdomen has positive, nontender, and nondistended.
Neurological exam in grossly nonfocal.


Rationale:
The endocrine system is not recognized by the CPT or CMS (1995 guidelines) and thus it cannot be used for the comprehensive exam requirements as only organ systems are accepted for a minimum of 8 to support the level. ENT does not include the examination of the thyroid gland and there is no mention of neck masses or lymphadenopathy to qualify for the lymph system. I would defer to a companies coding policies for credit for ENT "Thyroid is central and not enlarged" statement. Most refer to the bullets in the ENT or Multi-system exam templates for support and guidance as to where to apply credit.

1997 Documentation Guidelines Rationale:
I agree with a.montaruli that the documentation only meets an Expanded Problem Focused examination. A minimum of 12 bullets are needed to be documented to meet a Detailed Multi-system exam and only eleven were found. I disagree that the abdomen can't be counted and I included the exact statement from the guidelines in the notes.
Constitutional: NAD (1 bullet)
Neck: Thyroid central (symmetry), not enlarged (2 bullets)
Resp: Clear to auscultation (1 bullet)
CV: No carotid bruits. Extremities reveal no edema. Heart is regular in rate and rhythm. (3 bullets)
GI: exam states "nontender" (1 bullet)


[Note per the 1997 Documentation Guidelines:
Elements with multiple components but with no specific

​

numeric requirement (such as "Examination of liver and spleen") require documentation of at least one component.
Psych: alert and oriented x 3 (1 bullet)
Neuro: nonfocual (1 bullet)
Integ: inspection/incision healed (1 bullet)
Total: 11 bullets

I hope this breakdown helps the provider see where the information is given credit and additional information as to where the guidelines can be applied.