In response to your 95 exam question-let's say the patient presents with left wrist pain. Here are two examples of the exam portion:
"Vitals are noted, patient appears to be in mild discomfort. The exam of the wrist shows moderate swelling and tenderness."
Compare that to:
"Vitals are noted, patient appears to be in mild discomfort. Range of motion of the left wrist appears to be decreased with moderate tenderness noted when compared with that of the right wrist. There are contusions on the palm of the hand presumably from the injury. Negative tinel's sign, vascular appears intact, no obvious malformations".
I would consider the first exam expanded problem focused since there is limited documentation of the wrist exam with the additional documentation of the vitals. The second exam of the wrist is much more detailed and shows the in-depth documentation of wrist exam when compared to the first example. The provider may have done the same exam in both examples, but, in my opinion, the documentation of the first note is not detailed.
I hope this helps,
P.S. Still waiting for my CPMA results...really hoping we all hear something today! Good luck all!
Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC
AAPC ICD-10-CM/PCS Training Expert
Kindness is contagious-PASS IT ON!