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What level of exam?

  1. Default What level of exam?
    Medical Coding Books
    Please help what level?? He is alert, oriented and cooperative. He appears to be in good health. Exam of the right knee demonstrates no effusion today. He does have mild pseudolaxity of the lateral ligament. Posterolateral corner structures are normal. ACL PCL and MCL are normal. He does have medial tenderness. The lateral joint line is sensitive particulary in the mid portion. THe patellofemoral joint is also somewhat painful with what appears to be a slightly thick plica. Hip exam demonstrates minor tightness with terminal intenal rotation and terminnal abduction but otherwise looks good. Thanks

  2. #2
    Milwaukee WI
    Default Ortho NOT my specialty
    Ortho is not my specialty .. but

    If you are using 1995 guidelines you could argue that this is a detailed exam: "extended" exam of affected body area and other related systems (in this case constitutional)

    F Tessa Bartels, CPC, CEMC

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