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Podiatry e/m-exam documentation

  1. #1
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    Springfield, Mo
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    Question Podiatry e/m-exam documentation
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    I am new to Podiatry and could use some advice on exam documentation. What level would one call this exam?? The DR seems to think it is a "detailed" exam. Maybe it is for podiatry?? By 95 or 97 guidelines I can only come up with PF. This exam is of the left foot only. THANKS for any help.

    On examination, pain is noted on palpation on the plantar and lateral aspects of the left arch area. Mild tenderness is also noted on active eversion against resistance along the course of the peroneal tendons of the left foot. No pain is noted on application of tuning fork on the area. No pain is noted on passive range of motion of the midtarsal joints or subtalar joints. There is no edema or erythema noted. There is no sign of acute infection or cellulitis noted on the area.

  2. #2
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    Quote Originally Posted by rashleygaeke View Post
    I am new to Podiatry and could use some advice on exam documentation. What level would one call this exam?? The DR seems to think it is a "detailed" exam. Maybe it is for podiatry?? By 95 or 97 guidelines I can only come up with PF. This exam is of the left foot only. THANKS for any help.

    On examination, pain is noted on palpation on the plantar and lateral aspects of the left arch area. Mild tenderness is also noted on active eversion against resistance along the course of the peroneal tendons of the left foot. No pain is noted on application of tuning fork on the area. No pain is noted on passive range of motion of the midtarsal joints or subtalar joints. There is no edema or erythema noted. There is no sign of acute infection or cellulitis noted on the area.
    Per the liberal 1995 3 organ systems/body areas = Expanded Problem Focused exam.

    Musculoskeletal = pain is noted on palpation on the plantar and lateral aspects of the left arch area. Mild tenderness is also noted on active eversion against resistance along the course of the peroneal tendons of the left foot. No pain is noted on application of tuning fork on the area. No pain is noted on passive range of motion of the midtarsal joints or subtalar joints.

    Cardiovascular = There is no edema or erythema noted.

    Integumentary = There is no sign of acute infection or cellulitis noted on the area.

    If they documented Constitutional it would still be EPF. He would have to add another organ system to get detailed for 1995.
    Mickie Kummer, CPC, CPMA, CRC, CPC-I, AAPC Fellow

  3. #3
    Location
    Springfield, Mo
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    382
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    Thanks! I appreciate the reply and any help I can get.

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