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Exam documentation - Conjunctivae/Lids: within normal limits

  1. #1
    Default Exam documentation - Conjunctivae/Lids: within normal limits
    Medical Coding Books
    We have a new dermatologist to our office, following is how she is documenting her exam:

    General Appearance: well-developed, well nourished, no apparent distress
    Mood/Affect: cooperative
    Orientation: alert and oriented x 3
    Scalp/Hair: within normal limits
    Head/Face: macule on left mandible
    Conjunctivae/Lids: within normal limits
    Lips/Teeth/Gums: within normal limits
    Oral Mucosa/Tongue: within normal limits
    Neck/Thyroid: within normal limits
    Right Upper Extremity: within normal limits
    Left Upper Extremity: within normal limits
    Nails/Digits: within normal limits

    So, I'm confused by her documentation. Would this be expanded based on 95 and 97 guidelines? Any advice would be much appreciated! For the 97 I was giving a point for RUE and a point for LUE, but unsure if this is accurate.

  2. #2
    Default Derm exam
    I actually would say it is a detailed exam. Per 97guidelines you have 12 bullets, you are correct by giving 1 for each extremity that was examined. If you use 95 then it will depend on your interpretation of detailed vs. expended problem focused. Some carriers consider examination of 2-4 body areas/organ systems an EPF exam and 5-7 a detailed exam. Others consider 2-7 body areas/organ systems for both EPF and Detailed, so it becomes rather subjective how to interpret EPF vs. Detailed exam. Yet I'd still say it is a detailed exam.

    Sofia Delmas, MS, CPC

  3. #3
    Thanks-That makes sense.

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