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Physical exam

Heidi Posted Thu 17th of October, 2013 13:35:11 PM

will you please tell me what level you would code this exam using the 95 E&M guidelines:

Vitals:temp 98.6 weight 47.3 pulse 64
General appearance: He is alert and oriented x3. He is thin built.
Eyes: anicteric
Neck: supple, no masses
Lungs: mild inspiratory and expiratory wheezing
Heart: regular rate and rhythm
Abdomen:nondistended, non tender, no ascites.
Extremities:No edema, no dupuytren's contractures or palmar erythema.
Neuro: non-focal

SuperCoder Answered Thu 17th of October, 2013 23:18:38 PM

We have answered similar Q in another thread.

Using 1995 guidelines this is a detailed exam: 7 areas/systems documented: vitals, eyes, CV, Resp. GI, Neuro and psych. One in detail.

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