Wiki Body area vs organ system

[Eileen Downs]

I am looking for some information on how to determine if an exam finding should be counted as a body area or organ system when using the 1995 guidelines. Is anyone aware of a good publication or reference material that gives clarification?

 

[FTessaBartels]

The Body Areas are:
1. Head/face
2. Neck
3. Chest, breasts, axillae
4. Abdomen
5. Genitalia, Groin, Buttocks
6. Back, Spine
7. EACH extremity

The Organ systems are:
1. Constitutional (vitals, appearance)
2. Eyes
3. Ears, nost, mouth, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Skin
10. Neurologic
11. Psychiatric
12. Hematologic / Lymphatic / Immunological

NOTE: For the comprehensive exam you need 8 or more of the organ systems.

F Tessa Bartels, CPC, CEMC

 

[Eileen Downs]

Thank you for your response. I think I may not have been as specific as I should have with my question. I am looking for specific information on when to count exam findings that could go either as a body area or organ system. My training has been that if the exam element directly pertains to a organ system, the organ system should be counted first. For example the statement "abdomen soft, nontender, no hepatosplenomegaly". Some auditors would count this as exam of the body area abdomen. Others may count this as GI. Personally, I would count it as GI. A statement such as "abdomen obese, nondistended" does not tell us anything specific to the organ system so I could see where that would count that as a body area. What if the provider comments only on positive bowel sounds? Some say it should be counted as abdomen, others say GI. Another example would be "extremities no edema." The statement could be counted as CV or extremeities. Most of the time I have seen it counted as CV since edema pertains directly to the CV system but I have seen it counted both ways. The services being audited are typically hospital admissions so a comprehensive exam is often the level that needs to be supported. It absolutely can affect the outcome of the audit if an auditor counts a statment as an body area when it should be counted as an organ system.

 

[FTessaBartels]

Auditing E/M is open to interpretation

It's the nature of Auditing E/M that it is open to interpretation. And it is one of the great frustrations of the 1995 guidelines that they are so vague and so open to different interpretations.

For a comprehensive exam under the 1995 guidelines you need 8 or more organ systems. Body areas don't count at all.

What I usually do is look at the 1997 bullets (Yes, I know, you're using 1995 guidelines - that's what we use here) to see if the phrasing matches under any of the systems outlined in 1997 guidelines. If so, I count it for that system. In your example for extremity edema that falls under CV, so that's the system I'd give credit for. While "clubbing/cyanosis" falls under musculoskeletal.

As for "bowel sounds present" - If I was checking for 8 systems to equal a comprehensive exam, I would give credit as GI system under 1995 guidelines, even though there's no bullet for 1997 guidelines. I would NOT count "obese abdomen" as GI for a comprehensive exam, but I would count it as body area Abdomen if I were looking at a Detailed exam.

I'm sorry I can't give you any more specific guidance or proof.

F Tessa Bartels, CPC, CEMC

 

[rthames052006]

It's the nature of Auditing E/M that it is open to interpretation. And it is one of the great frustrations of the 1995 guidelines that they are so vague and so open to different interpretations.

For a comprehensive exam under the 1995 guidelines you need 8 or more organ systems. Body areas don't count at all.

What I usually do is look at the 1997 bullets (Yes, I know, you're using 1995 guidelines - that's what we use here) to see if the phrasing matches under any of the systems outlined in 1997 guidelines. If so, I count it for that system. In your example for extremity edema that falls under CV, so that's the system I'd give credit for. While "clubbing/cyanosis" falls under musculoskeletal.

As for "bowel sounds present" - If I was checking for 8 systems to equal a comprehensive exam, I would give credit as GI system under 1995 guidelines, even though there's no bullet for 1997 guidelines. I would NOT count "obese abdomen" as GI for a comprehensive exam, but I would count it as body area Abdomen if I were looking at a Detailed exam.

I'm sorry I can't give you any more specific guidance or proof.

F Tessa Bartels, CPC, CEMC

I just love your explaination Tessa. With me getting prepared to take the CEMC all this is helping me put it together for using the score sheet that was provided with the Practicum.

My Compliance Manager said the exact same thing as you, which helped me over the weekend.

Thanks for all your help!