For a detailed exam on 1995 guidelines you need an EXTENDED exam of the affected body area or organ system, plus other related system(s).
I tell the doctors that they have to cover at least four elements of exam of the affected body area/system before I count it as extended. Then give me one other related system and I'll count it as detailed.
For example, patient with injury to right forearm. (I'm making this up off the top of my head ... ortho coders be kind ...)
Pleasant 15 YO, well groomed, in NAD. Right forearm has numerous bruises and contusions. Normal range of motion without pain at elbow. Patient has pain with with dorsal flex of wrist, and ROM is limited as result. No edema. Pulse strong. No tingling or numbness in fingers. No cyanosis.
I would say this was an extended exam of the affected body area (left forearm), plus other related systems (Constitutional). (Of course you could count it as 5 organ systems, too: Skin, MS, CV, Neuro, Constitutional)
Hope that helps.
F Tessa Bartels, CPC, CEMC
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