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Level of exam based on 95 guidelines

  1. #1
    Default Level of exam based on 95 guidelines
    Medical Coding Books
    Vital signs are noted normal. There are no head or neck lesions. No lymphadenopathy or thyromegaly. Lung fields are clear without rales or rhonchi. Cardiac exam: No murmurs, rubs or gallops. Abdomen is soft and nontender. Extremities are warm and well perfused. There is no overt synovitis. There is decreased pin prick sensation over the right median nerve dermatome but the findings are slight.

    Ok, 95 is not my comfort zone for leveling, so I am asking for others take on this.

    I say that this is a detailed exam on 95 and expanded problem focused on 97. Vitals were listed elsewhere so I am counting


    Am I wrong calling this a detailed exam on 95?


    Laura, CPC

  2. #2
    Cons - vitals
    Skin - lesions
    Lymph - no lymphadenopathy
    Neck - thyromegaly
    Resp - lungs clear
    CV - auscultation
    GI - soft/nontender
    MS - warm/no synovitis
    Neuro - sensation

    I have 8 organ systems and 1 body area (neck) I would credit it as comprehensive. Comprehensive only allows you to use 8+ organ systems and no body areas. I used the "no lesions on head and neck" as skin ... that gives you an extra organ system and a comprehensive exam. If you compare to the 1997 skin examination ... it states something like ... "examination for rashes, lesions, ulcers, etc of head and neck" So, I'd definitely count it.

    What do you think?
    Last edited by ARCPC9491; 07-17-2009 at 10:05 AM.

  3. #3
    This is from the AAPC CEMC practice test. They are saying this is an EPF for both 95 and 97 guidelines.

    I see your point on the skin. I was looking at it from the body area perspective and not counting it towards systems but it could/should be counted as skin, I think. Which based on the audit tool AAPC supplied that would make it comprehensive.

    I take my exam tomorrow and I was taking the practice test again today. I am hoping the tests are actually reviewed and not just graded.

    Thanks for the input, it is greatly appreciated.

  4. #4
    North Carolina
    Good Luck Laura! I know you will do great!!
    Rebecca CPC, CPMA, CEMC

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  5. #5
    Thanks Rebecca, I really appreciate that.

    I sure hope so. I am probably over thinking things, I do that sometimes, lol.

    Laura, CPC

  6. #6
    Milwaukee WI
    Default Detailed 1995 exam
    Well ... I would count this as Ashleigh did for 1995 - i.e. comprehensive.

    But maybe I can shed light on where the AAPC is coming from in saying it is an EPF exam by 1995 guidelines.

    For a detailed exam on 1995 guidelines you need an "extended" exam of the affected body area or organ system AND other related systems. This documentation doesn't seem to provide an extended exam of any one area, so that may be why they wouldn't consider it detailed. (But why they wouldn't count lesions on neck/head as skin is another story ... I'm guessing they're stuck on the "head and neck" part of that phrase.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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