Detailed or Comprehensive Exam???

kfrycpc

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Can someone tell me if this a Detailed or Comprehensive exam? I say Comprehensive because it is 8 organ systems.

exam.jpg
 

cdeak01

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This is not a comprehensive exam, which requires 8 organ systems. You have the following elements:

Organ systems:
constitutional, ENT, Respiratory, Cardiovascular, lymph, skin

Body areas:
head, neck
 

kfrycpc

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This is not a comprehensive exam, which requires 8 organ systems. You have the following elements:

Organ systems:
constitutional, ENT, Respiratory, Cardiovascular, lymph, skin

Body areas:
head, neck

Thank you. I'm trying to get my head around this for the auditing exam. Can you mix and match body areas and organ systems?
 

kfrycpc

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Can you help me with this one? I think I've almost got my head around it:

PE:

Constitutional: Overall appearance - age appropriate.
Eyes: Conjunctiva - Right: Normal, Left: Normal.
Nasopharynx: Turbinates - Right: Normal, Left: Normal. Tonsils - Normal. Oropharynx - Normal.
Respiratory: Auscultation - Normal.
Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No JVD noted.
Vascular: Pulses - Dorsalis pedis: Normal.
Abdomen: Auscultation - Normal.
Extremity: No edema.
Psychiatric: Orientation - Oriented to time, place, person & situation. Appropriate mood and affect.

I marked it as below but I'm not sure if I should have marked extremity since both weren't mentioned. Should it have been marked Musculo?


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Last edited:

thomas7331

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I would rate this exam as 'detailed' for six to seven systems (seven if you count abdomen as GI). I would include the 'edema' in extremities as part of the cardiovascular system, (although I've had some providers argue with me that it could be consider lymphatic - but I think that's stretching it).

Most audit tools specify that you count either organ systems or body areas but not both, and they also require that a comprehensive exam use only organ systems - body areas not allowed for the highest level. The audit tool you've posted here shows body areas only for the PF exam and systems only for all of the others, which doesn't sound correct either, but guidelines on this do vary by payer and region.
 
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