I took AF and VSS to be part of the interval history - does not read like exam to me.
If you are using 1997 guidelines you would have to specify the values of three vital signs to get one point for constitutional, so you STILL do not get constitutional exam points for VSS.
Here's what I see as your only exam:
abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma
If you are using 1997 guidelines - here are the bullet points you can count:
* Examination of abdomen with notation of presence of masses or tenderness
* Examination of liver and spleen
* Examination for presence or absence of hernia
* Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
* Obtain stool sample for occult blood test when indicated
* Inspection of skin and subcutatneous tissue (e.g. rashes, lesions, ulcers)
* Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening)
I do not see that you get ANY points for abdominal/GI exam if you are using 1997 guidelines. The only bullet point you would get with this documentation would be for skin (because of the incision being C/D/I and the possible seroma) - and I'm being generous there.
F Tessa Bartels, CPC, CEMC
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