The 1995 guidelines are vague, and have never been clearly defined. Which is why they came out with the 1997 guidelines.
Thre are two schools of thought on what makes a detailed exam under 1995 guidelines.
Option 1: 5-7 body areas/systems It is easy to count these systems, but does that mean an "extended exam of the affected area"? I would argue it does not.
Option 2: an extended exam of the affected body area or system, plus other related systems. But what does this mean?
Nobody really knows. But if the chief complaint is sinus congestion and the exam is only "Nares patent" I'd argue this was NOT an extended exam.
On the other hand if your exam included "Sclera clear, lids inflamed and red, oral mucosa moist, thick nasal secretions, facial swelling and tenderness" I would argue this is an extended exam of the affected area. Then all you would need is other related systems (e.g. lungs clear to auscultation, Temp 99.3) and you'd have your detailed exam.
Hope this helps.
F Tessa Bartels, CPC, CEMC
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