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Wiki body area or organ system?

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GAcoder

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I'm soon taking the E&M exam and am getting anxiety attacks studying for it. I still have questions about E&M. Exam: body areas neck and abdomen.
What elements will make neck and abdomen an organ system? neck-supple and ROM are not accepted for organ system. I get so confused on this.
Can somebody help me? Thanks so much!
 
Neck and abdomen are body areas not systems except there are times the provider will check the lymphatic system when checking the neck and will mention they checked the Lymph glands or states "no masses", etc. I then count it as Hematologic/Lymphatic/Immunologic.

Also, when they are checking the abdomen and mention bowel sounds, etc. the they are checking the Gastrointestinal System.

The thing to really watch is extremities. Unless they mention about their joints, muscles, etc. or state "no clubbing", you have to be careful with this area. If you are coding using the body areas, the provider also has to be specific that they reviewed or examined both upper and lower limbs or total right or left side. If they are specific you can only give them credit for arms or legs or right or left.

Also HEENT - The provider may list HEENT on his/her note but only review or examine the eyes or only the ears, nose and throat but not both. They only get credit for one or the other if both are not noted as being reviewed / examined.

I hope this helps. Best of luck.

Lorri Tolliver, CPC, CPMA, CEMC
 
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Thank you Lorri. Thank you for your help. If neck has ROM can you count that as musculoskeletal? As for HEENT if ears and nose and throat each have an element do you count the separate elements or does HEENT only get one point?
Sometimes I see edema in extremities, can that count as cardio?
I was taught to do it this way but Im not sure its correct.
 
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