E/M exam question - On the physical exam

AmandaW

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On the physical exam, 95 guidelines, would you count Extremity as one or 4?
 
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Body Area vs Organ System

The 1995 guidelines do not allow for counting "bullets" as the 1997 guidelines do.

So, depending on the level of exam
Problem Focused, Expanded Problem Focused or Detailed
You may count body areas, and EACH extremities counts separately.

Comprehensive
You must have 8 or more organ systems, ONE of which is the musculoskeletal system. So whether you examine one joint or twenty you get ONE organ system.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

AmandaW

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Yes, thank you.

On subsequent days like when they're in the hospital they can use body areas and the CPT book says "each extremity" under where it displays the body areas. I was wondering if that was each as in 4, or just counts as 1 body area, Looks like 1.
 

AmandaW

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...but counts as 4 if they note examining all? Usually in the template it will say something like bilateral ankles show edema, otherwise negative by the EXTREMITY category...maybe they need to seperate them to show 4 areas in the template.
 
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