If you are using 1995 guidelines AND he at least has vitals or respiratory/lungs in addition to this full cardiac exam you have a detailed exam (definition: an extended exam of the affected organ system/body area plus other related organ systems)
To get a comprehensive exam on 1995 guidelines you need to document exam of at least 8 (out of 12) organ systems.
If you are using 1997 general multi-system exam you have:7 bullets = EPF exam. (not counting the "extras" he sometimes does)
If you are using 1997 CV specialty exam you have: 7 bullets = EPF exam (again, not counting the 'extras' he sometimes does)
Google the 1997 E/M guidelines and then look through to find the Cardiovascular exam. You'll see that to get a comprehensive CV exam you need to document ALL the bullet points in the shaded areas, and at least one element in each of the unshaded areas. So you would need (In addition to what you say he always does):
* any THREE of the following vital signs: sitting or standing BP; supine BP; pulse rate & regularity; respiration; temp; height;weight (3 vitals gets you ONE bullet point)
* general appearance of the patient
* Assessment of respiratory effort
* auscultation of lungs
* exam of abdomen w/ notation of masses or tenderness
* exam of liver and spleen
* obtain stool sample for occult blood for patients being considered for throbolytic or anticoagulant therapy
* brief assessment of mental status, including
- orientation to time place and person
- mood and affect
ALSO would need at least one bullet from each of the following areas:
To get a comprehensive general multi-system exam on 1997 guidelines, you need to have documented 2 bullet points from each of 9 different systems.
I don't see any way you'll get to comprehensive exam with the type of documentation you've indicated this physician provides.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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