Palmetto GBA has stated " the 1995 detailed exam requires documentation of throw through seven body areas or organ systems with more detail. Detailed exam would consist of at least two finding for at least two body areas or two organ systems."

For example, "Pt A&O with pleasant mood and affect. Examination of Lt Knee shows incisions clean, dry and intact, good capillary refill. Skin is unremarkable. Full ext present, flex to 95. No signs infection or RSD. Neurovascularly intact distally. Good endpoint w/ anterior and posterior drawer. Rt knee normal exam -ROM, STR, capillary refill, stability and sensation all intact.

I score the exam as Expanded (1995: 5 organ systems // 1997:2 ROM, 2 STR, 1 Inspection, 1 Skin, 2 Psych, 1 Neuro, 1 Cardiovascular)

However, with the Palmetto GBA guidance, should the exam be enough for a detailed exam? The other coder in our office thinks I should require at least 4 findings for two body areas, which honestly is what I’ve been doing.