Wiki 97 guidelines for the Musculoskeletal exam

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angi.max@mana.md

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Under the 97 guidelines for the Musculoskeletal exam, for the bullet Assessment of muscle strength and tone with notation of any atrophy and abnormal movements, would “musculoskeletal- Is there presence of abnormal movement? No” be sufficient to receive credit for that bullet?

Thoughts?

thank you.
 
My thoughts are no. I would want to see a specific statement indicating the provider specifically addressed muscle strength and tone. Something like "muscle strength is 5/5 with normal tone and no abnormal movement." Or simply "muscle strength and tone is normal" would do it for me.

But that's just my opinion. I am learning about E/M auditing on my own and am not yet certified in this area. I'm sure I could be easily swayed to change my thoughts by a more experienced E/M auditor.

Becky Hardin, CPC
 
I agree with Becky. There is no mention of muscle strength and tone and that is crucial to that element. 97 guidelines are so much stricter than 95 guidelines in these types of areas.
In addition - this type of wording "musculoskeletal- Is there presence of abnormal movement? No" makes me concerned about the physician's use of EHR templates that include elements that may/may not be relevant to the NPP, or may even be auto-populated.
I hope I haven't just muddied the waters more!
Kim
 
I agree.
I attended a webinar yesterday and asked the same question.
The auditor said she would allow it.
But, i dont agree with that. I feel like the bullet states assessment of muscle strength and tone, and this statement doesnt mention anything about muscle strength and tone.

thank you.
 
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