Jamie Posted Wed 20th of April, 2016 15:44:18 PM
Per 1995 guidelines, expanded exam is a limited exam of 2-7 body area/organ systems, detailed exam is 2-7 with extended exam of at least one body area or other related organ system. What is considered a extended examination of one body area or organ system? Below is an example of an exam done by a provider in our office. Would this qualify for a Expanded Problem Focused Exam or a Detailed exam?
Physical Examination: Wt: 234 lb Ht/Ln: 72 in BMI: 31.7 BP: 129/82 Pulse: 79 RR: 16 Temp: 97.6F Sat: 99
Well-nourished male in no acute distress. Normal gait. Right inner thigh reveals an erythematous patch measuring approximately 3 x 3 cm. The center area that is violaceous but not raised. There is an erythematous serpiginous border. There is no scale. Nontender to palpation.
SuperCoder Answered Thu 21st of April, 2016 08:22:12 AM
As per the given scenario examination performed is Extended Problem Focused.
Jamie Posted Thu 21st of April, 2016 12:12:15 PM
I am confused.. 95 Guidelines show 2-7 (99213) and 2-7(w/1 Detailed)99214. Per given scenario we had Constitutional (1) and Integumentary(2). Integumentary (2) with Integumentary being detailed which would qualify for 99214. So how can I differentiate what is considered an extended vs detailed since the 95 guidelines do not differentiate that?
SuperCoder Answered Fri 22nd of April, 2016 06:53:36 AM
For detail examination an extended examination of the affected body area(s) and other symptomatic or related organ systems are required. For different specialty please follow undermentioned link to understand EPF vs Detailed exam.