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Physical exam help

  1. Default Physical exam help
    Medical Coding Books
    I use the 95 guidlines can you tell me how many areas and systems you can see in this dicatation and what they are just a little consfused on what I can count

    Physical exam: The patient is a well-developed well-nourished male in no acute distress. Examination of the left ankle demonstrates diffuse swelling. There is no erythema but he does have some ecchymosis. Range of motion is somewhat limited secondary to pain. He has 1+ laxity to anterior drawer testing. He has no pain with inversion testing. He is sensitive to palpation over the distal third of the fibula. He is nontender over the medial malleolus. He is neurovascularly intact distally.

    Height 6 foot 0 inches, weight 230 pounds, blood pressure 141/75

    Thanks so much grandmacora

  2. #2
    Default
    Physical exam: The patient is a well-developed well-nourished male in no acute distress. Examination of the left ankle demonstrates diffuse swelling. There is no erythema but he does have some ecchymosis. Range of motion is somewhat limited secondary to pain. He has 1+ laxity to anterior drawer testing. He has no pain with inversion testing. He is sensitive to palpation over the distal third of the fibula. He is nontender over the medial malleolus. He is neurovascularly intact distally.

    Height 6 foot 0 inches, weight 230 pounds, blood pressure 141/75

    per 95 guidelines I find 4 systmens reviewed
    constitutional
    musculoskeletal
    neurologicial
    integumentary
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

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