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Extent of Examination

  1. Default Extent of Examination
    Medical Coding Books
    PHYSICAL EXAMINATION: He is a well-developed African-American male who appears about his stated age of 43. Pupils are equal and reactive. Extraocular movements are full and without nystagmus. Conjunctivae are mildly icteric and red. Fundoscopic exam is normal. Strength is 5/5 in all proximal and distal muscle groups tested. Finger-to-nose and heel-to-shin maneuvers are performed smoothly and without ataxia. Reflexes are brisk and symmetric. Babinski sign is absent bilaterally. Gait and station are normal. The remainder of his cranial nerves are also normal. Mental status appears to be normal in terms of memory, recall, and language functions.

    It was recorded that this physical examination received 2 pts for NEUROLOGICAL.

    I am seeing "Extraocular movements" as 1, and "cranial nerves are also normal" as 2, and "Reflexes are brisk and symmetric" as 3.

    Am I incorrect?
    Adam L. Shoop CPC
    You will be successful in whatever you choose to do,
    and light will shine on the path ahead of you. Job 22:28

    Only because of God, my father, and Jesus Christ,
    did I make it into this field so smoothly. Thank you God!

  2. #2
    Milwaukee WI
    Default Extraocular movement = cranial nerves
    Extraoccular movements are part of the cranial nerves ... so you only count this once.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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