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Detailed or Comprehensive Exam? 95 or 97?

  1. Default Detailed or Comprehensive Exam? 95 or 97?
    Medical Coding Books
    I have a new Cardiologist and in leveling her exam with 95 and 97 guidelines I cant get past detailed. Am I missing something? What guidelines did you use?

    The physical examination showed a well appearing and well nourished male iin no distress with no visible cyanosis. Examination of the head was unremarkable. The eyes were unremarkable. The ears were not assessed. The neck was unremarkable. Examination of the mouth and throat was remarkable for the cleft lip and palate. The thoracic cage was unremarkable. There was no prior surgical wound or incision. Palpation was deferred. The lung exam showed unlabored breathing with no retractions. Auscultation revealed good, equal breath sounds. Furthermore, the breath sounds were clear with no rales. Her cardiac exam showed a precordial impulse at the left chest. There was a normodynamic impulse. The pulses (carotid, radial, femoral and brachial) were normal with no exceptions. There was no right femoral -brachial delay. The heart rate was normal with a regular rhythm. The heart sounds showed a normal S1 with a normal S2. S2 was normally split. Manuevers were not performed. At most, a grade 1-2/6 nonspecific SEM was noted at the left sternal border while lying down. No clicks were noted. No rubs were noted. No additional sounds were noted. Abdominal exam revealed a soft and nondistended abdomen with no bruits. Ascites was not apparent. No tenderness was appreciated. Liver size was normal. A spleen was not palpable. No masses were noted. Extremity examination was normal without clubbing, edema and cyanosis. The neurologic examination showed no focal or gross deficits. There were no additional findings.

  2. #2
    Milwaukee WI
    Default Detailed
    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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