Sunday, January 20, 2008

Content and Documentation Requirements (1997 CMS guidelines)

Level of Exam Perform and Document:

  • Problem Focused - One to five elements identified by a bullet.
  • Expanded Problem Focused - At least six elements identified by a bullet.
  • Detailed - At least twelve elements identified by a bullet.
  • Comprehensive - Perform all elements identified by a bullet; document every element from the area in blue text and at least one element in each other area.
MUSCULOSKELETAL EXAMINATION
  • Constitutional Measurement of any three of the following seven vital signs:
    • sitting or standing blood pressure,
    • supine blood pressure,
    • pulse rate and regularity,
    • respiration,
    • temperature,
    • height,
    • weight (may be measured and recorded by ancillary staff)
    • General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
  • Head and Face
  • Eyes
  • Ears, Nose, Mouth,
  • and Throat
  • Neck
  • Respiratory
  • Cardiovascular
    • Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)
  • Chest (Breasts)
  • Gastrointestinal (Abdomen)
  • Genitourinary
  • Lymphatic
  • Palpation oh lymph nodes in neck, axillae, groin, and or other location
  • Musculoskeletal
    • Examination of gait and station
    • Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas:
      • head and neck;
      • spine, ribs and pelvis;
      • right upper extremity;
      • left upper extremity;
      • right lower extremity; and
      • left lower extremity.
    • The examination of a given area includes:
      • Inspection, percussion andior palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
      • Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture
      • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
      • Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
    • Note: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element iscounted separately for each body area. For example, assessing range ofmotion in two extremities constitutes two elements.
  • Skin
    • Inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafe‐au‐lait spots, ulcers) in four of the following six
    • areas:
      • head and neck;
      • trunk;
      • right upper extremity;
      • left upper extremity;
      • right lower extremity; and
      • left lower extremity.
    • Note: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitute two elements.
  • Neurological/Psychiatric
    • Test coordination (e.g., finger/nose, heel/ knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
    • Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
    • Examination of sensation (e.g., by Couch, pin, vibration, proprioception)
    • Brief assessment of mental status including:
    • Orientation to time, place and person
    • Mood and affect (e.g., depression, anxiety, agitation)

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