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Using 95 guidelines verus 97

  1. #1
    Default Using 95 guidelines verus 97
    Medical Coding Books
    Physical Examination: Reveals a pleasant 44-year-old female in no acute distress. Blood pressure 122/80, pulse 92, repsirations 18, and temperature 97.8, HEENT: Within normal limits, CHEST Clear Skin Normal turgor, warm, dry. Neurologic: Cranial nerve II through XII are grossly intact.

    Would say according to the 95 guidelines that this is a expanded problem focused exam/limited exam of 2-7 systems?

    If I would use the 97 guidelines, would I have one bullet for recording 3 vital signs, 1 bullet for Skin, 1 bullet for respiratory, 1 for ENMT, 1 for Neurological
    Making this only a Problem focused exam?

    Would you say I counted the bullets right?

  2. #2
    Overland Park, KS
    I'll offer my opinion here....

    Using the '95 guidelines, I would say this is indeed an expanded problem focused exam, but not because of the 2-7 systems. The '95 guidelines state:

    Expanded Problem Focused -- a limited examination of the affected body area or organ
    system and other symptomatic or related organ system(s).

    I can't really tell from the info you provided here what the affected body area/organ system is, but it appears to me that this provider only did a limited exam here which is an EPF.

    Using the '97 guidelines, I count the following bullets:

    Constitutional: 2 bullets (vitals and general appearance)
    Skin: 2 bullets (inspection and palpation)
    Neurologic: 1 bullet (cranial nerves)

    I'm giving two bullets here for the skin because the provider states the skin is normal tugor (inspection) and warm, dry (palpation). I don't see where you are getting respiratory from because there does not appear to be anything documented for the respiratory. I would also not give credit for HEENT. The provider does not state here exactly what is within normal limits. Is it the head, eyes, ears, nose, or throat? The documentation does not say which.

    Putting this together, I get 5 bullets for a problem focused exam using the '97 guidelines.

    Any other opinions?
    Last edited by dballard2004; 06-18-2010 at 12:29 PM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  3. #3
    Thank you for the response. This was very helpful.

  4. #4
    Overland Park, KS
    You are very welcome! Glad I could help.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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