Wiki how would you code this exam?

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renifejn

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This is my first time doing during outside of an AAPC test environment so I'm a little iffy on my coding. How would you count this exam? Is saying that a full skin exam was done listing the areas and stating normal sufficient?

PHYSICAL EXAM
A full skin exam (inspection and palpation of skin and subcutaneous tissues
of the head/face, neck, chest, abdomen, back and all 4 extremities) was
performed. If not described in more detail below = within normal limits.

*General Exam-WDWN NAD*

Skin/Mucosa/Hair/Nails *Erythematous scaly papules and plaques involving
the trunk, upper extremities, antecubital fossa, lower extremities,
popliteal fossa, hands, feet and buttock area . Crusting is present around
the ankles as are several open fissures. Pustules are absent. Estimated
total body surface area affected by eczema is 65 %. One 8mm crusted papule
on vertex.
*Eyes/ENT* Sclerae white, PERRL and EOMI
*CV, Resp, GI, GU, Hem/Lymph, Psych--*Not assessed.*
*
*Musc Skel*--Full range of motion of all extremities. No edema. No
deformities..

Thank you so much in advance for your help!
 
I would call this detailed based on the 97 skin exam guidelines.

Laura, CPC, CEMC
 
Detailed

Detailed based on 1995 guidelines (Extended exam of the affected body area/system and other related systems).

Yes, stating the full skin exam was done and all findings normal except where otherwise noted IS sufficient (especially since your doc actually lists all the various body areas of skin that were examined).

F Tessa Bartels, CPC, CEMC
 
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