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grandmacora

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If I understand right can I bill a extended exam for this dictation?? I use the 95 quidlines. This gets so confusing the more you do !!!!!!!!!!!!!


Physical exam: The patient is a well-nourished male in no acute distress. Examination of the left knee demonstrates no effusion. Range of motion is normal. There is no erythema or ecchymosis. He is very sore to palpation over the patellar tendon. He is also sore with patellofemoral compression testing. There is no medial or lateral joint line tenderness. Tibial rotation testing is negative. Ligaments are stable.

Right knee demonstrates a similar physical exam findings with tenderness over the patellar tendon and pain with patellofemoral compression testing, although much less so than the left knee. Patellar alignment looks good on both knees.

Thanks so much for your time
 

missy874

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I'm sticking my neck out there because of the other exam posting which many coders disagreed with my level, but I do say its detailed. Multiple components of the organ system (musc) were examined to support extended and you have multiple organ systems (const, integ).

I have been auditing for several years now, and in my present position my audits are audited by an outside consulting firm (with different auditors within firm). I have consistently passed with flying colors. But eh, you never know.
 

Evelyn Kim

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I did orthopedic coding for a long time and I see an expanded problem focused exam under the 95 guidelines (knee, ligaments, etc). But since the 95 guidelines list 2-7 for both the EPF and Detailed, I would look at the MDM to guide me. Also if this is a new or established patient can have an effect on the final code selected.
 
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