1995 Exam

stpat

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We use the 1995 guidelines for E/M coding and I have been advised that there are other statements to look for that would qualify for the eight organ systems needed for a comprehensive exam such as:

cyanosis - could count as skin
clubbing - could count as musculoskeletal
carotid bruits, thyromegaly, lymphadenopathy - could count under lymphatic
bowel sounds, nontender, organomegaly - could count under GI

Are these okay to count as organs? Are there any other keywords to look for that might be listed under body areas that would actually qualify as an organ system?
 

dmaec

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yes, they'd count in the organ systems. (that's exactly where I'd count them too) ... Any exam/issues related to the organ system counts towards "that" organ system, (body area). It doesn't have to be the word itself "integumentary", "musculoskeletal", etc... the related exam information is what's pulled out of the note and marked under the appropriate organ system/body area .
there are many different words that refer to each organ system/body area.
{that's my opinion on the posted matter}
 

dmaec

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rebecca - I know my "co-coder" puts it under there :) ... and, I think your software is correct also. Though, I can't say that I always toss it under cardiovascular ;)
 
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