Wiki Detailed examination

[Griffin]

Per the evaluation and management books it states for a detailed examination 2-7 in more depth (extended exam of affected body area/systems and other related systems. How does other coders determine a detailed (extended exam of the affected body area) for a detailed examination? I was told it is considered detailed if the provider looks, feel or touch and listens does all three things to the body area.. I would appreciate any input.

 

[FTessaBartels]

Limited vs Detailed

Here's an example that may help

LIMITED EXAM
Patient presents with painful wrist following fall on ice yesterday.
Left wrist is slightly swollen without bruising.
Xray shows no fracture.
Patient advised to use Ibuprofen, apply ice pack and use Ace bandage to restrict movement.

DETAILED EXAM
Patient present with painful wrist following fall on ice yesterday.
Well nourished, slender female in NAD. BP 120/60. Left wrist slightly swollen as compared with right. Fingers without tingling or cyanosis. No obvious contusion or abrasion. Tender to touch. Range of motion limited by pain. Pain 4/10 when held still; 7/10 when flexed. Contralateral wrist with full rainge of motion, no pain, no swelling, no tingling.
Xray shows no fracture.
Patient advised to use Ibuprofen, apply ice pack, and use Ace bandage to restrict movement.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[cheermom68]

Ngs

If NGS is your carrier they have just come out with a new auditing tool. I listened to an webinar yesterday on it. They consider an expanded problem focused exam 2-5 body areas/organ systems and a detailed exam 6-7 body areas/organ systems.
LeeAnn