One more time ...
The 1995 guidelines for exams are as follows.
Problem focused - a limited examination of the affected body area or organ system.
EPF - a limited examination of the affected body area or organ system, AND other symptomatic or related organ system(s)
DETAILED - an extended examination of the affected body area or organ system, AND other symptomatic or related organ system(s)
You already have the comprehensive down - 8 or more organ systems.
Note that technically you can have only the affected body area and ONE other related/symptomatic organ system examined and you can still qualify for a detailed exam ... IF ... big, red IF ... you have an extended exam of the affected body area.
So if the presenting problem (affected body area/organ system) is the head, then you can count the body area. If the presenting problem is belly ache, you CANNOT count "head atraumatic" as a body area.
Trauma isn't mentioned anywhere on the 1997 bullet points either.
It's very frustrating for those of us in Pediatrics because a very common "exam" of a baby is "head atraumatic, normocephalic, anterior fontanelle soft and flat" ... nowhere in the 1995 exam unless it's the baby came in with a bump on his head (but then it shouldn't be "atraumatic," should it? S I G H).
Hope that helps.
F Tessa Bartels, CPC, CEMC
Hope that helps.
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