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Level of Exam - if anyone could help me

J

jmcalhaney

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I was wondering if anyone could help me out with this. I am coding for a Gastro office where the majority of exams look the exact same. They are generated by an EMR and look like the following:

WT: 190lbs. General: The patient is awake, alert, and oriented x3, in no apparent distress. HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No lymphadenopathy. No pallor or icterus. NECK: Supple, no neck or thyroid mass. No JVD. HEART: Regular rate and rhythm. No murmur, gallop, or rub. CHEST: Clear to auscultation bilaterally. No rales, rhonchi, or wheezes. ABD: Soft, nontender, and nondistended. No hepatosplenomegal. Good bowel sounds in all quadrants. EXTREMITIES: No clubbing, cyanosis, or edema

I am seeing that they reviewed 8 systems which would qualify for a comprehensive exam, but I don't feel that this is a comprehensive review. I really feel that it is an expanded problem focused exam since they are not reviewing anything in detail. Any opinions are appreciated. Thanks
 
Unless I am missing something I am only seeing seven areas examined but it is still a detailed exam. You have at least 12 elements identified by a bullet in two or more aeas.
 
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