Lymphatic
Palpation of lymph nodes in
Neck
two or more areas:
Axillae
Groin
Other
Musculoskeletal
Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1)
head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity;
5) right lower extremity; and 6) left lower extremity. The examination of a given area
includes:
Inspection and/or palpation with notation of presence of any misalignment,
asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or
contracture
Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements
Neurologic
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg,
Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)
Psychiatric
Description of patient’s judgment and insight
Brief assessment of mental status including:
orientation to time, place and person
recent and remote memory
mood and affect (eg, depression, anxiety, agitation)
All about Evaluation and Management (E and M) procedure codes. Office visit, hospital visit, Hospital care procedure codes. Service codes 99201,99203,99205, 99211, 99212, 99213, 99214, 99215,99221, 99222, 99223, 99231, 99233, 96150 - 96154, G0425 - G0427. How and what code to use for proper E & M Billing.
Wednesday, July 13, 2016
Neurologic, Psyciatric, Lymphatic and Musculoskeletal - Elements of Exam
Labels:
document,
E & M visit Basic,
Physical exam
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