Question Exam elements for 1995 guidelines

wynonna

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For Exam counting: For EPF, we need 2-4, Detailed: 5-7, and Comprehensive: 8 or more body/organ systems. Must we have 2 points at least per body/organ system for 1995 guidelines? ie shouldn't there be at least 2 points per body/organ system to count as a system? Or is this just true for constitutional?
So comprehensive would require 8 body/organ systems palpated/observed and must contain at least 2 elements per system, for a total of 16 points at least to qualify as comprehensive exam?
That is the way I was trained. Is this still true?
So for example: for cardiovascular to count as a system, documentation should have at least 2 elements, such as " no edema in extremities and normal rate and rhythm?"
Thank you
 

Orthocoderpgu

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Your projecting 1997 GL to 1995 GL, which you can't do. There are no bullets or points with 1995. In 1995 there are only body areas & systems. In 1997 there are bullets or points. If you were trained that way, you were trained incorrectly or misunderstood. For 1995 don't try to apply points to the exam.
 
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wynonna

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I used to word "points" as a counting mechanism for body areas. We need to somehow count the body/organ systems to come up with problem focused, Expanded problem focused, detailed, and comprehensive. Are you familiar with a way to determine exam without counting?
 

thomas7331

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Some auditors and audit tools state that there must be two documented exam findings within a body area or system in order to 'count' it, but this is not specified in the 1995 guidelines and is not a universal requirement.
 

Orthocoderpgu

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I used to word "points" as a counting mechanism for body areas. We need to somehow count the body/organ systems to come up with problem focused, Expanded problem focused, detailed, and comprehensive. Are you familiar with a way to determine exam without counting?
Of course you need to count, but you can't count the 1997 bullets and try to apply them to the 1995 rules. The 1995 guidelines only count systems and body areas, that's it. There are no bullets or points like the 1997 guidelines. In 1995 you can get a "Detailed" exam with only two body areas, if the body areas are examined in "more detail". The problem is that the 1995 GL don't address what "more detail" is. So there can be grey area when using them. For now, it's much easier to get a 99214 in 1995 than 1997 so I like the 1995 guidelines. In 2021 all this goes out the window and MDM is used, nothing else.
 
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