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I need help coding this exam! Help

  1. Default I need help coding this exam! Help
    Medical Coding Books
    Pt is a well developed female. Inspection of her spine reveals she has diminished lordosis. Palpation reveals tenderness a the midline and paraspinal areas. Very limited. She can not go into full extension but can go into almost complete flexion. Deep tendon reflexes are symetrical in the upper and lower extremities. Sensation is intact. Normal strength. Tenderness at the SI joint and trochanteric bursae with pain on flexion, abduction and external rotation. There are obvious surgical sites where the acoustic neuromas were with deficits at that area. Surgery is well healed. Mild tenderness to palpation of the head. Straight leg raising is positive bilaterally. Flexion, abduction and external rotation positive for thigh pain and groin pain.

  2. #2
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    Quote Originally Posted by anggand@aol.com View Post
    Pt is a well developed female. Inspection of her spine reveals she has diminished lordosis. Palpation reveals tenderness a the midline and paraspinal areas. Very limited. She can not go into full extension but can go into almost complete flexion. Deep tendon reflexes are symetrical in the upper and lower extremities. Sensation is intact. Normal strength. Tenderness at the SI joint and trochanteric bursae with pain on flexion, abduction and external rotation. There are obvious surgical sites where the acoustic neuromas were with deficits at that area. Surgery is well healed. Mild tenderness to palpation of the head. Straight leg raising is positive bilaterally. Flexion, abduction and external rotation positive for thigh pain and groin pain.
    What have you got so far? This looks like a musc and neuro exam to me. I'd probably use the 1997 exam guidelines on this one, without scoring it out myself I'd probably use either musc or neuro template.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
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    detailed exam by 1997 guideline. DTR's/sensation are neuro, rest is M/S.
    Badboy
    CPC, CPMA

  4. #4
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    Default Post op?
    Quote Originally Posted by anggand@aol.com View Post
    Pt is a well developed female. .... There are obvious surgical sites where the acoustic neuromas were with deficits at that area. Surgery is well healed. ...

    If this is a post-op visit, it makes no difference. CPT 99024

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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