Ms. Smith is a 55 year old female with nausea and vomiting and I was consulted by (Doctor) for assisting with further management. She has been having nausea and vomiting since Monday and not able to keep anything down. She has a history of acid reflux on medication for that every other day. Denies of abd pn. She is on laxatives for constipation but still struggles to have bowl movement. Denies of diarrhea. She had left BKA 2 years ago for diabetes. she is also blind. History of chronic kidney disease on dialysis. she is morbid obese with BMI 41 and is bedridden.
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Physical Exam Element Extremity?
Physical Exam:
General: Well developed, well groomed, in no acute distress.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
GU: has small epidermal cyst in left scrotum
Extremity: no edem ** Can I count this towards the MS or Skin? Or is it just rolled in with the CV?**
Thank you,
Nichole
HPI element radiates location or quality
Would this be 2 elements
Radiates= quality
Left arm= location
Or
Radiates to left arm= location
HPI element : Modifying Factor
Example:
Patient is a 58-year-old Caucasian female with sore throat, headache, chills and fever for past 3 days. Pain is rated as 5/10 on pain scale. Patient is experiencing dull pain. She tried lozenges yesterday.
Per my understanding, HPI elements are Duration, severity, associated symptoms and quality. Please correct me if I am wrong.
My question here is patient has tried lozenges, however, no relief is documented. Can I count this against modifying factor?
“moderate in severity” as HPI element
E & M exam element guidelines
or 2-4 elements for Expanded problem-focused and 5-7 for detailed to:
2-5 elements for expanded problem focused and 6-7 for detailed?
That means exam level may change from 4 to 3 if only 5 elements are used
By elements I mean a body/organ system with at least 2 points per area on body.
According to Medicare, now at least 6 body/organ systems will be necessary for a level 4 (detailed) exam
Is this right?
Are there any updated E and M audit worksheets out there to reflect new exam requirements?
thanks