Exam

msingh23

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Needs some guidance on determining what Exam this justify billing for Orthopedics Office level. Trying to see if this qualifies for a comprehensive exam base on Dr

Pulses
RLE pulses: present and palpable
LLE pulses: present and palpable

General
Appearance: well developed, well nourished, in pain

Lymphatic
Nodes: no LE edema

Gait
Inspection: normal

Skin
Appearance: Normal

Lumbar Spine/Pelvis
Range of motion: inc pain w lumbar flexion and limited to 45 deg w pain, dec pain w ext+T
Palpation: + TTP R LS ps

Special Tests
Slump: positive R
IR/ER: negative
SI joint: negative
SLR: positive R

Right Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength, 5-/5 EHL, 4/5 eversion and gastoc

Left Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength

Neurologic
Coordination: normal coordination
Reflexes: 2+, symmetric, no pathological reflexes
Sensation: intact

Mental Status Exam
Orientation: oriented to time, place, and person
Mood and affect: no alteration in mood or affect.

Thanks
msingh23
 

sivagurulingam

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My opinion : This exam has qualifies for Detailed exam as per 1997 guideline single organ system examination .

If vitals and Musculoskeletal examination of another one area like head & Neck or any Upper Extremity has examined means it's qualifies for comprehensive exam.
 

msingh23

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Thanks for your input.
Vitals are listed in chart however the addtional Musculoskeletal examination of another one area like Head & Neck OR any Upper Extremity has not documentaed in chart so this will still not qualifies for comprehensive exam?

Thanks
msingh23
 
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