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Physical Exam

  1. Default Physical Exam
    Medical Coding Books
    Having difficulty deciding, under 1995 guidelines, whether this could be considered complete single organ system examination. Appreciate input...

    PHYSICAL EXAMINATION: Physically, well-developed, well-nourished, very muscular and stocky gentleman. His vital signs were 140/104, 84 and 18. Temperature was 97, blood pressure settled to 136/92. Head, eyes, ears, nose and throat unremarkable. His chest and lungs are all completely within normal limits. The right arm shows a little dimpling of the biceps tendon insertion just proximal and anterior on the right elbow. It is tender. There is no bunching or tenderness of the biceps itself. Biceps flexion is normal activity. I grossly watched him and he was able to turn his arm fairly easily.

  2. #2
    Location
    Jacksonville, FL River City Chapter
    Posts
    74
    Default
    I wouldn't consider six findings regarding one extremity to be a complete examination of the musculoskeletal system.

    Seth Canterbury, CPC, ACS-EM

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Not to me
    I agree with Seth. What you have here is a Detailed exam.

    F Tessa Bartels, CPC, CEMC

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