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ortho exam

  1. Default ortho exam
    Medical Coding Books
    This is a new pt exam with the 95 quidlines what do you find please help thanks so much
    as a coder I am questioning what I code today

    Physical exam: Patient is a very pleasant male. He is alert and oriented x3 and very cooperative. Examination of the left foot demonstrates slight prominence at the vase of the fifth metatarsal. There is no swelling. There is no erythema. He has tenderness to palpation directly over this area. This reproduces where he's been having his pain. He has slight discomfort laterally with peroneal strength testing but has good strength. There is no instability around the ankle.

    Height: 5 feet 8 inches, weight 135 pounds, blood pressure 147/67

  2. #2
    Milwaukee WI
    Default It depends
    For the 1995 guidelines, some carriers use 2-4 body areas/organ systems as EPF; and 5-7 as detailed. If this is the case for you, then you have an EPF exam.

    On the other hand ... the guidelines actually state that a DETAILED exam is an extended exam of the affected body area(s), and other symptomatic or related organ systems. Your physician documents an extended exam of the affected body area, plus constitutional and psych. So you could make an argument that you have a DETAILED exam.

    I've asked my specialty groups to come up with written protocol as to what constitutes an "extended exam of the affected body area" (and while they're at it, what equals a "complete exam of a single organ system"). This "definition" is then placed in the Compliance plan to outline how THEY define the term, and internal audit is based on that information.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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