Wiki Exam 95 Guidelines

[Naveen Rachagolla]

PHYSICAL EXAMINATION: Demonstrates a 6 feet 4 inch, 282 pound with a body mass index of 33. His blood pressure is 140/84. He is accompanied today by his wife. The patient is noted to have warm, well perfused hands with 2+ palpable radial pulses bilaterally. Range of motion of the wrist, MP and IP joints is grossly normal. He has a positive Tinel sign over the median nerves in both wrists. He does show some mild flattening of the thenar eminence on the right hand-side though his grip strength is overall excellent. No formal 2-point discrimination tests or grip strengths were performed today. His nerve conduction studies were reviewed.

Hi, all

I coded the above exam as detail base on 95 DG, I could see 3 systems on the note, CEMC syudy guide says...
EPF EXAM ( 2-7 Organ Systems/Body Areas Limited )
Detail EXAM ( 2-7 Organ Systems/Body Areas in Detail )
Can someone confirm this...

 

[MnTwins29]

Agree

Keeping in minid that the 95 DG's allow for a wide interpretation, I would agree with this as I saw at least four points made for the nervous system. Some payers/MACs would want to see at least 4 or 5 systems/areas documented with the detail, some want more points. But just IMO, I would say there is enough detail here to warrant it. If someone says EPF based on some other payer's guideline, I wouldn't say he or she is wrong either. The great grey area of the 1995 exam!

 

[Naveen Rachagolla]

Keeping in minid that the 95 DG's allow for a wide interpretation, I would agree with this as I saw at least four points made for the nervous system. Some payers/MACs would want to see at least 4 or 5 systems/areas documented with the detail, some want more points. But just IMO, I would say there is enough detail here to warrant it. If someone says EPF based on some other payer's guideline, I wouldn't say he or she is wrong either. The great grey area of the 1995 exam!

Thank you Lance, for your valuable interpretation and making it clear.