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cardio exam level

  1. #1
    Smile cardio exam level
    Medical Coding Books
    This is for an Inpt cardiology consult, billing 99255. I am do not think this fits comprehensive level, but maybe I am wrong, or thinking about it too much? I question the musculo exam part? Looking for input before contacting doctor. Thanks.

    General: No acute distress. (Note does have 3/7 vital signs tho)
    Eye: Normal conjunctiva.
    HENT: Normocephalic, Oral mucosa is moist.
    Neck: No carotid bruit, No jugular venous distention.
    Respiratory: Lungs are clear to auscultation, Respirations are non-labored.
    Cardiovascular: S1 (Normal), S2 (Normal/Split), No murmur, No edema, Precordium quiet, no thrill or heave, No clicks present.
    Arterial pulses: Upper extremity, Lower extremity, Within normal limits.
    Gastrointestinal: Soft, No organomegaly.
    Musculoskeletal: No swelling.
    Integumentary: Warm, Pink.
    Integumentary exam: Not cyanotic.

  2. #2
    Location
    Coeur d'Alene, Idaho
    Posts
    134
    Default
    Are you using 1995 or 1997 guidelines. I believe this would meet criteria for a comprehensive physical exam under 1995 guidelines.
    Thanks,
    Amanda Briggs, BS, CPC, CPMA, CCC, CEMC
    Coeur d'Alene, ID Chapter

  3. #3
    Location
    Baton Rouge
    Posts
    1,241
    Default
    Quote Originally Posted by JLViolet View Post
    This is for an Inpt cardiology consult, billing 99255. I am do not think this fits comprehensive level, but maybe I am wrong, or thinking about it too much? I question the musculo exam part? Looking for input before contacting doctor. Thanks.

    General: No acute distress. (Note does have 3/7 vital signs tho)
    Eye: Normal conjunctiva.
    HENT: Normocephalic, Oral mucosa is moist.
    Neck: No carotid bruit, No jugular venous distention.
    Respiratory: Lungs are clear to auscultation, Respirations are non-labored.
    Cardiovascular: S1 (Normal), S2 (Normal/Split), No murmur, No edema, Precordium quiet, no thrill or heave, No clicks present.
    Arterial pulses: Upper extremity, Lower extremity, Within normal limits.
    Gastrointestinal: Soft, No organomegaly.
    Musculoskeletal: No swelling.
    Integumentary: Warm, Pink.
    Integumentary exam: Not cyanotic.
    I don't think I would consider this Comprehensive under '95 DG...the muskulo isn't specific enough, IMO, to warrant credit. I'm coming up 6 with Organ systems: Eye, ENT, Resp, Cardio, GI, Integ, for a Detailed Exam.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  4. #4
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Quote Originally Posted by mhstrauss View Post
    I don't think I would consider this Comprehensive under '95 DG...the muskulo isn't specific enough, IMO, to warrant credit. I'm coming up 6 with Organ systems: Eye, ENT, Resp, Cardio, GI, Integ, for a Detailed Exam.
    I agree that it does not meet comprehensive - however if the doctor did document the vitals, then I would add Constitutional, making it 7 systems. If he had said joint swelling instead of just swelling, then he would have comprehensive!
    Jodi Dibble, CPC

  5. #5
    Default
    Thank you all for the input. I was having difficult time seeing it as comprehensive as well.

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