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?
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join