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Comprehensive Exam

  1. #1
    Default Comprehensive Exam
    Medical Coding Books
    Please review this exam to see if this meets a Comprehensive level of exam. Thanks as always for your help.
    Physical Examination: On physical exam today, the patient is a pleasant female with height of 5 feet 9 inches tall, weight of 187 pounds, and pulse of 80.
    General: She is well appearing, in no acute distress, well-developed and well-nourished.
    Musculoskeletal: On inspection of the lumbar spine, she does have two well healed scars laterally over her lower back from previous liposuction procedure. She has no significant tenderness to palpation across her lumbar spine. She has full range of motion with forward bending as well as extension. She is able to toe raise and heel walk with no difficulties. Testing of the L1 through S1 dermatomes and myotomes shows intact sensation; 5/5 strength bilaterally. Peripheral pulses are intact. Reflexes are symmetric. She has no nerve root tension signs. On inspection of her pelvis she does seem to have a lower right hemipelvic compared to the left side.
    Skin: No lesions.
    Neurological: No focal motoer or sensory deficit. Coorination is intact, oriented x 3. Reflexes are normal.
    Cardiovacular: No edema or varicosities. Peripheral pulses +2/4 bilaterally throughout.

  2. Default
    Hi,

    I would consider that detailed not comprehensive.

    Hope this helps,

    Joanne

  3. #3
    Default
    Thanks Joanne. Could you tell me why you think that?

  4. #4
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    Nashville AAPC Chapter
    Posts
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    Default
    You will need 8 organ systems for a comprehensive exam for 1995 Guidelines. For 1997 Guidelines you will need at least 2 bulleted elements from 9 areas/systems from the General Multi-system Exam.

    You only have 6 organ systems documented, even if one stretched the edema for Edocrine (which some practices do), you are still short.

    Please review this exam to see if this meets a Comprehensive level of exam. Thanks as always for your help.
    Physical Examination: On physical exam today, the patient is a pleasant female with height of 5 feet 9 inches tall, weight of 187 pounds, and pulse of 80. ConstitutionalGeneral: She is well appearing, in no acute distress, well-developed and well-nourished.
    Musculoskeletal: On inspection of the lumbar spine, she does have two well healed scars MS laterally over her lower back from previous liposuction procedure. She has no significant tenderness to palpation across her lumbar spine. She has full range of motion with forward bending as well as extension. She is able to toe raise and heel walk with no difficulties. Testing of the L1 through S1 dermatomes and myotomes shows intact sensation; 5/5 strength bilaterally. Peripheral pulses are intact. Reflexes are symmetric. She has no nerve root tension signs. On inspection of her pelvis she does seem to have a lower right hemipelvic compared to the left side.
    Skin: No lesions. ITG
    Neurological: No focal motoer or sensory deficit N. Coorination is intact, oriented x 3.Psych Reflexes are normal.
    Cardiovacular: No edema or varicosities. Peripheral pulses +2/4 bilaterally throughout. CV

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