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Wiki 1997 Musculoskeletal exam

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jllgood

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When auditing by the 1997 Musculoskeletal Single Organ Exam, would you consider "bilateral hips" to be under the "pelvis" body area, or Right and Left Lower Extremity?
 
Personally, I think it could fall under either depending what the physician is looking for. When I see SLR (example) normally I see this as ROM for the hips/pelvis. In other instances, they may be looking for pain (example) and I may credit this as lower extremity. Again, I think it depends on the documentation; what is being examined and why.
 
Musculoskeletal Exam

I agree with Rebecca on this. I've had to code for both situations and it was specific to the provider's documentation and payor guidelines. I also use EncoderPro and I have it under notes for payors.
 
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