I used 1995, 1997 general multi-specialty, AND 1997 cardiovascular specialty exam guidelines.
Can't find a way to get above detailed BECAUSE ...
She gets no credit at all for "unremarkable" ... so we can't count eyes.
If she had said what was unremarkable about the eyes (PERRLA or sclera clear) we could give her a mark for another system on the 1995 guidelines and you could get to comprehensive.
As it stands you have 7 systems: Constitutional, ENT, Respiratory, CV, GI, MS and neuro. You can't count body areas for the comprehensive exam, so even if she had expanded on "neck unremarkable" or "head unremarkable" it wouldn't help here.
I get 12 bullet points in 6 systems on the 1997 guidelines multi-specialty exam guidelines. I get only 10 bullet points in 5 systems on the 1997 cardiovascular specialty exam guidelines.
So detailed exam ... all the way.
I like to tell my docs "unremarkable = uncodable = unpayable" to try to get them to stop using this phrasing. (It's an uphill battle.)
F Tessa Bartels, CPC, CEMC
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