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Detailed examination

  1. Default Detailed examination
    Medical Coding Books
    As I understand it, a detailed examination is when the physician examines 2 to 7 areas or systems, with 4 findings in the affected system; therefore a total of 8 or more findings overall. The way I originally understood it, the 4 findings, is not counted as a bullet, it is only required to qualify for a detailed exam, which makes a distinct difference in a expanded problem focused exam(just 2 to 7 areas or systems w/o 4 findings in the affected area). I just want to make sure if I should or should not count the 4 findings in the affected area. Thanks!

  2. #2
    Default new thread
    Can someone please tell me how to post a new thread?? Thanks

  3. Default
    Go to the bottom of the main page of the E/M section, it will say new thread, click there.

  4. Default
    http://www.empiremedicare.com/cbtcou...m%20Levels.pdf


    Detailed. An extended examination of affected body area(s) and other
    symptomatic or related organ system(s) (up to 7, at least two items per system).

    According to this source on empiremedicare.com, 2 items per system is enough to qualify as detailed exam per 1995 guidelines.
    Thanks,
    Jagadish, CCS-P, CPC

  5. #5
    Default
    Quote Originally Posted by letisha View Post
    As I understand it, a detailed examination is when the physician examines 2 to 7 areas or systems, with 4 findings in the affected system; therefore a total of 8 or more findings overall. The way I originally understood it, the 4 findings, is not counted as a bullet, it is only required to qualify for a detailed exam, which makes a distinct difference in a expanded problem focused exam(just 2 to 7 areas or systems w/o 4 findings in the affected area). I just want to make sure if I should or should not count the 4 findings in the affected area. Thanks!
    In your case, I would check with the insurance carrier directly, each insurance has their "own rules" regarding what a detailed exam is. Where I live I use our local medicare carrier's criteria.

    Hope this helps,
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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