Wiki Exp. problem focused exam or detailed exam??

[m.matos@chcfl.com]

We are in debate in the office on whether this exam is considered Exp. problem focus or detailed using the 1195 Guidelines.
Would like some other opinions:

General Examination:
GENERAL APPEARANCE: alert and oriented x 3, no acute distress, well nourished. NECK: no thyromegaly, no lymphadenopathy, non-tender. HEART: regular rate and rhythm, normal S1S2, no murmurs, click or rubs. LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales, regular breathing rate and effort. ABDOMEN: soft, Nontender/Nondistended, bowel sounds present. EXTREMITIES: no cyanosis, no clubbing, no edema. PERIPHERAL PULSES: symmetrical bilateral.

Assessments
1. Insulin dependent diabetes mellitus - 250.01 (Primary)
2. HTN - 401.9
3. Hyperlipidemia - 272.4
4. Gastritis - 535.50
5. Obese - 278.00

 

[bedforak1]

I scored it to be a detailed exam.

 

[CPC CEMC]

EPF vs DET

Utilizing the 95 DG, this example reveals a Detailed (DET) exam.

Some use the convention
2 to 4 documented exam elements for an EPF and
5 to 7 documented exam elements for a DET

Some use the 4 x 4 tool
4 elements examined in 4 body areas or 4 organ systems

and others have established internal policies defining clinical implications to differentiate between the 2 to 7 EPF and DET designations.

Also, you may want to contact your MAC to find out what convention they are using.

 

[m.matos@chcfl.com]

Thank you.