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Thread: Help what level exam is this????

  1. #1

    Default Help what level exam is this????

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    Please help me and let me know what level this is and how you came up with that thanks so much Cora

    Physical exam: The patient is a well-developed well-nourished female in no acute distress. She is alert and oriented x3 and very cooperative throughout the exam. Examination of the right elbow demonstrates no erythema or ecchymosis. She does have a loss of 2° of terminal extension. Flexion is good. She has good range of motion with pronation and supination. She does have pain with resisted wrist extension and resisted supination. She has good grip strength, however she does have pain on the lateral although with this. She is somewhat tender over the lateral epicondyle. She is nontender over the medial epicondyle. She has no pain with resisted wrist flexion and resisted pronation. She is neurovascularly intact distally.

  2. #2
    Join Date
    Apr 2007
    Location
    Olympia, WA
    Posts
    11

    Default

    I use an E/M "cheat sheet" for coding office visits. I got it from a co-worker, who got it from someone at a conference. Using 1995 guidelines I came up with expanded problem focused exam. There were 5 organ systems documented (out of 12), and limited body areas examined. I hope this helps you!
    DezaRae Malone, CPC

  3. #3
    Join Date
    Apr 2007
    Location
    Milwaukee WI
    Posts
    4,451

    Default What did you get?

    Cora ... before I answer ... what did you get, and why?

    Are you using 1995 or 1997? If you are using 1995, the guidelines do NOT give how many body areas/systems are requied for EPF vs Detailed ... what they say is that the EPF exam is "limited exam of the affected body area/organ system, plus any related or symptomatic systems." While the detailed exam is an "expanded exam of the affected body area/organ system, plus any related or symtomatic systems." SOME carriers have interpreted 1995 guidelines to say that FOR EXAMPLE 2-4 BA/OS = EPF; 5-7 BA/OS = Detailed. You need to know what YOUR guidelines are.

    If you are using 1997 guidelines, you'll need to count the bullets.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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