Physical Exam E/M Bullets

KRED

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I'm trying to determine if I'm coming up with the correct number of bullets. We use the 97 guidelines

The physical exam states

Vital Signs: Temp 98.2, Pulse 51, Resp Rate 100, BP 157/87, Pulse ox 98%
General Appearance: The pt is lying in the bed. he is not in any medical distress, however, he is uncomfortable and he staes tht he has significant abdominal pain. he cannot find a position where he is comfortable.
Psych: No signs of anxiety or depression. Alert and oriented x 3.
HEENT: Normocephalic, atraumatic. no rashes seen on the face.
Eyes: Nonicteric. pupils equally round and reactive to light
Neck Tracheal midline. No JVD
Resp: Clear to auscultation bilaterally. No wheeze or rhonchi.
Cardiac: RRR. No murmurs
Abd: Not distended. No guarding or rebound. Significant epigastric pain to palpation. He does have diminished, but present bowel sounds.
Musculoskeletal: 5/5 strength throughout. No lower extremity edema.

I am coming up with 14 bullets.
 
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Detailed Exam 1997

I come up with only 13 bullets, but regardless, it's still a detailed exam by the 1997 guidelines.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

ollielooya

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I am coming up with 12-13 bullets as well and even though we have detailed exam as explained by Tessa, would like to know how bullets were assigned.. Feel a little unsure about not awarding any bullets for the HEENT. This is my rationale but would like validation.

Using 97 guidelines:
Constitutional (2)
Eyes (2) or does the Nonicteric count as part of the examination of pupils and irises along with the PERLA? which would take it to (1)
Neck (1)
Respiratory (1)
Cardiovascular (2)
Gastrointentinal (1)
Musculoskeletal (1)
Skin (1)
psychiatric (2)

---Suzanne E. Byrum CPC
 

sullivak

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Here's how I distribute the bullets.

Using 97 guidelines: [multi-system]
Constitutional (2)
[1 point - not in medical distress, uncomfortable - gen appearance; Vitals - 1 point]

Eyes (2) or does the Nonicteric count as part of the examination of pupils and irises along with the PERLA? which would take it to (1)
[1 point for pupils and irises (PERRLA), 1 point for conjuctivae, lids for the nonicteric sclera]

Neck (1) [1 point for exam of neck]

Respiratory (1) [1 point for ausc of lungs]

Cardiovascular (2) [1 point for ausc of heart; 1 point for no lower extremity edema]

Gastrointentinal (1) [1 point for G680]

Musculoskeletal (1) [0 points; This wording is not specific enough in my opinion to warrant points in musculoskeletal. What did they examine, specifically?]

Skin (1) [1 point for inspection of skin for the mention of no rashes]

psychiatric (2) [1 point for alert and oriented x3, and 1 point for mood, affect-depression]

I count 12 points.
 
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