E/M Bullets on hands


Local Chapter Officer
Topeka, KS
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I am a little confused.:confused: We have a hand surgeon in our office and I find it a little hard and confusing when trying to count my bullet points on his exam. Mostly confused when he states patient had intact FDS, FDP, AND EDC function to all digits or on physical examination patient is non-tender to FCR, ECRL, and ECRB.

The problem I am having is I have one coder explaining that by the doctor stating the FDS, FDP, and EDC is only one bullet point all together. Then I have another coder explaining to me it is consider three bullet points since they are individual.

So as you can see I am confused and hoping someone can help clarify whether each one is consider individual or if he is examining this that they are all together?

Please Help!! Any information would be very helpful!

Thank you,

Last edited:


True Blue
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Unfortunately you're working in a specialty for which the 1997 guidelines don't have a corresponding exam, but even so I don't think either of the coders are using the guidelines correctly as you've described. I'm assuming your practice is using 1997 guidelines if you're counting bullet points? If so, then here is how the bullets are defined in the musculoskeletal specialty exam, which is probably closest to what you're provider is doing:

Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:

Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain (eg, straight leg raising), crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

NOTE: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements.

Based on this, as long as you're not looking for a comprehensive exam, you could count each hand separately, with a bullet point for each one of these four types of measurements, but not each individual muscle of the hand as one of your coders is stating. You could get additional bullet points in the skin and neuro sections of the exam if those are documented as well. Since you're in a unique specialty, I might suggest you get your coding team and providers to work together, and perhaps consult with an outside auditor, to develop some internal guidelines on how you will assess your exam documentation. Having this would give you consistency and would be very helpful in the event you ever had a payer audit of your E&M levels.