Wiki 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
 
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.
 
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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