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Standard Code Book (SCB)  

Examination Codes

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Code Examination Standards
03  DIABETIC EYE EXAM  Used to document the administration of a diabetic eye exam. 
28  DIABETIC FOOT EXAM, COMPLETE  Used to document the administration of a formal diabetic foot exam. Examination should include assessment of protective sensation, foot structure, biomechanics, vascular status, and skin integrity. Test sensation with the 10g monofilament on the plantar aspect of the first, third, and fifth digits and metatarsal heads of each foot. Inspect the foot for deformities and altered biomechanics including hammer and claw toe deformatis, bunions, Charcot foot, and body prominence, and excessive pronation. Conduct a vascular assessment by feeling for dorsalis pedis and posterior tibial pulses on each foot. Alternatively, assess vascular status with an ankle brachial index (ABI). 
29  FOOT INSPECTION  Used to document the administration of a simple foot check or inspection. Shoes should be removed and feet inspected for acute problems at each visit. 
30  DENTAL EXAM  Used to document a dental exam. 
34  INTIMATE PARTNER VIOLENCE  Used to document screening for current and lifetime exposure to Intimate Partner Violence/Domestic Violence (IPV/DV). 1. Talk to the patient alone in a safe, private environment. 2.Know the reporting requirments in your state and inform patients about any limits of confidentiality prior to conducting screening. 3. Ask the patient simple, direct questions such as: a.Are you in a relationship with a person who physically hurts or threatens you? b.Did someone cause these injuries? Was it your partner or spouse? c.Has your partner or ex-partner ever hit you or physically hurt you? d.Do you (or did you ever) feel controlled or isolated by your partner? e.Has your partner ever forced you to have sex when you didn't want to? Has your partner ever refused to have safe sex? f.Has any of this happened to you in a previous relationship? Note: If the IPV/DV screen is positive, a health and safety assessment should be performed and findings documented. Refer to a social worker or domestic violence advocate, if possible. 
35  ALCOHOL SCREENING  Used to document screening for riskly alcohol drinking habits. Various exams are recommended in different settings. 1. For adults in the outpatient setting, ask the patient: a.On average, how many days per week do you drink alcohol? b.On a typical day when you drink, how many drinks do you have? c.What's the maximum number of drinks you have had on a given occasion in the last month? 
36  DEPRESSION SCREENING  Used to document a brief screening for depression. The screening cannot be the basis of a diagnosis, it can only indicate whether further evaluation is warrented. 1.Ask the patient "Over the last two weeks, how often have you been bothered by any of the following problems?": a.Little interest or pleasure in doing things. b.Feeling down, depressed, or hopeless. 
37  FALL RISK  Used to document screening for fall risk in patients, especially those patients age 65 or older. Ask the patient if they have fallen in the past year or identify a fall with presentation for medical attention from the health record. 
38  NEWBORN HEARING SCREEN (RIGHT)  Used to document a newborn hearing screening. Administer a hearing exam on the newborn's right ear. 
39  NEWBORN HEARING SCREEN (LEFT)  Used to document a newborn hearing screening. Administer a hearing exam on the newborn's left ear. 
40  NUTRITIONAL RISK SCREENING  Not visible in EHR, but is needed to be active for something in the nutrition package. 
42  VTE RISK ASSESSMENT  VTE = Venous Thromboembolism Risk. Used to document an assessment of the risk for a patient to experience a thrombolic or embolic event. Conduct a VTE Risk Assessment. 
43  SUICIDE RISK ASSESSMENT  Used to document the administration of a suicide risk assessment. Administer a suicide risk assessment. There is no recommended or standardized tool. 
 13 Record(s)