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Wiki Is this a Detailed or EPF EXAM?

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jojo1uf

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Is this exam Detailed if following 1995 guidelines? I think it qualifies for a EPF on both the 1995 and 1997 guidelines.

Please let me know what you think. Thanks!



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OBJECTIVE

BP (!) 172/90 | Pulse 68 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Ht 5' 9" (1.753 m) | Wt (!) 152 kg (335 lb) | SpO2 94% | BMI 49.47 kg/m²

Physical Exam
Physical Exam
Constitutional: She is oriented to person, place, and time. Non-toxic appearance. She does not have a sickly appearance. No distress.
In wheelchair
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
Pulmonary/Chest: Effort normal and breath sounds normal.
Musculoskeletal: She exhibits edema. She exhibits no tenderness.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Lesion noted. She is not diaphoretic.
 
Detailed by 1995 general multisystem

Unless you code for a very specialized physician, I prefer 1995 guidelines 99% of the time. It is simply counting organ systems.
For coding, organ systems are defined as:
1) constitutional (vitals, general appearance)
2) eyes (inspection of conjunctivae & lids; exam of pupils & irises)
3) ears, nose, mouth & throat (external inspection of ears & nose (eg overall appearance, scars, lesions, masses); inspection of nasal mucosa, septum & turbinates; inspection of lips, teeth & gums)
4) respiratory (assessment of respiratory effort; percussion of chest; palpation of chest; auscultation of lungs)
5) cardiovascular (palpation of heart, auscultation of heart with notation of abnormal sounds & murmurs; exam of extremities for edema and/or varicosities)
6) GI (exam of abdomen noting presence of masses or tenderness; exam of liver & spleen; exam for presence or absence of hernia; exam of anus, perineum & rectum; occult blood test)
7) GU (inspection & palpation of breasts; digital rectal exam; pelvic exam including: external genitalia; urethral meatus; urethra; bladder; vagina; cervix; uterus; adnexa/parametria; anus & perineum)
8) lymphatic (palpation of lymph nodes in two or more areas: neck, axillae, groin, other)
9) musculoskeletal (inspection and/or palpation of digits & nails; exam of joints, bones & muscles of any of the following areas: head & neck; spine, ribs & pelvis; RUE; LUE, RLE; LLE)
10) skin (inspection of skin & subcutaneous tissue (eg rashes, lesions, ulcers); palpation of skin & subcutaneous tissue)
11) neurologic (exam of deep tendon reflexes (eg Babinski); exam of sensation)
12) psychiatric (description of pts judgment & insight; assessment of mental status including orientation to time, place & person; recent & remote memory; mood & affect (eg depression, anxiety, agitation)

1995 GENERAL MULTISYSTEM:
COMPREHENSIVE: 8 SYSTEMS
DETAILED: 5-7
EXP PROBLEM FOCUS: 2-4
PROBLEM FOCUS: 1

So, in your example, I count 7 organ systems which gets me to detailed.
1) constitutional 2) eyes 3) CV 4) respiratory 5) musculoskeletal 6) psych 7) skin
 
Last edited:
I definitely call this detailed. Even if someone were to say 1 or 2 of your organ system exams are not thorough enough to count, you would still be at 5 or 6. For example, musculoskeletal does not specify what extremities had edema or were examined. So if you don't give credit for that, you are still at 6.
 
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