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Wiki Counting Body Area and Systems 95

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medicalsec

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I know that you can count both body systems and organ systems for the other levels that are not comprehensive. I do use the 8 systems for comprehensive. If I was trying to bill a 99243, and was trying to meet the 5-7 critieria would I use the doctors statement Head: Without trauma as a body area or would I fit in in the MS area. It seems like most of the body areas can be fit into a system. Sometimes he just examines the thyroid when he does the neck, so I am assuming that this would fall in the body area caterory. Am I correct in thinking that most of these body areas can be converted into a system?

Thanks,

Dee
 
Affected BODY AREA

One more time ...

The 1995 guidelines for exams are as follows.

Problem focused - a limited examination of the affected body area or organ system.

EPF - a limited examination of the affected body area or organ system, AND other symptomatic or related organ system(s)

DETAILED - an extended examination of the affected body area or organ system, AND other symptomatic or related organ system(s)

You already have the comprehensive down - 8 or more organ systems.

Note that technically you can have only the affected body area and ONE other related/symptomatic organ system examined and you can still qualify for a detailed exam ... IF ... big, red IF ... you have an extended exam of the affected body area.

So if the presenting problem (affected body area/organ system) is the head, then you can count the body area. If the presenting problem is belly ache, you CANNOT count "head atraumatic" as a body area.

Trauma isn't mentioned anywhere on the 1997 bullet points either.

It's very frustrating for those of us in Pediatrics because a very common "exam" of a baby is "head atraumatic, normocephalic, anterior fontanelle soft and flat" ... nowhere in the 1995 exam unless it's the baby came in with a bump on his head (but then it shouldn't be "atraumatic," should it? S I G H).

Hope that helps.

F Tessa Bartels, CPC, CEMC

Hope that helps.
 
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