Wiki E & M bullets

[melzinser]

I am auditing E & M for an orthopedic practice. There is a common phrase used in many physical exam dictations: "both lower (or upper) extremities are neurovascularly intact." There is a great debate by the providers as to how many "bullets" should be given for this. I know what they are implying, but as an auditor, what should I credit this statement with?

 

[FTessaBartels]

None

Personally I would give NO bullets for that phrase, as I have no idea what - exactly - was examined. There is no "neurovascular" system ...

Was the physician looking for signs of edema? (1 bullet cardiovascular, IF so specified)
Was the physician checking deep tendon reflexes? (1 bullet neuro, IF so specified)
Was the physician examining muscle strength and tone? (2 bullets - one for EACH leg, IF so specified).

Hope that helps

F Tessa Bartels, CPC, CEMC