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Cards In This Set
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Examination is documented on what of the progress note?
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O for Objective- Info the Dr. gathers. Physical findings, report results.
(S.O.A. P)
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S-Subjective-Pts statement O-Objective-Dr.s px findings, report results
A-Assessment-Dr.s judgment, eval., dx
P-Plan-Plans to resolve the problem
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BA=Body Areas
OS=Organ System
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Subjective- Examination is the finding that the Dr. observes during the encounter.
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Dr. documents examination in record and the coder uses the documentation to code for the service.
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CPT manual recognized the BAs & OSs listed w/the exception of constitutional.
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CMS's 1995 (DG) Documentation Guidelines identify the 3 elements. General(Constitutional)/BA/OS
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General (Constitutional) consist of?
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8 elements - BP sitting, BP lying, Pulse, Respiration, Temperature, Height, Weight, General appearance
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Body Areas consist of?
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7 areas-Head(incl.head), Neck, Chest(incl. breasts & axillae), Abdomen, Genitalia(groin, buttocks), Back, Each extremity
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Organ Systems consist of?
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Ophthalm., Otolaryn., Cardiovascular, Resp., Gastro., Genito, Musculo., Integumentary, Neurologic, Psychiatric, Hematologic/Lymphatic/Immunologic
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NOTE: for the purpose of the examination, Endocrine is not listed as an OS although its listed in the OS in the ROS of the hx
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Example: examination w/4 Constitutionals, 2 Body Areas, and 9 Organ Systems
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BA - References to extremities that indicate a visual assessment such as clubbing, digits intact, no masses
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Cardiovascular system: References to extremity pulses, such as /flashcards/edit-card.php?id=24636#pedal or peripheral
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1 element in the constitutional area = to 1 BA/OS whether all 8 elements are checked or only 1 is checked
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But only 1 check if one area or all areas get examined for the otolaryngologic(ears, nose, mouth, throat)
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When all the extremities are referenced - 4 checks are placed on the form. (Auditing) Which are?
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1 ck for each arm and leg=4
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How many levels are there in an Examination?
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1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive
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What are the requirements of a "problem focused" Examination?
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Limited to the affected BA or OS identified by the cc. It involves 1 OS or 1 BA (body area).
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What are the requirements of a "expanded problem focused" Examination?
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Limited to 2-7 BA or OS & other related BAs or OSs of the affected area.
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