E/M for EXAM

rossirob001

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When counting Organ systems - if the physician marks NECK - supple, can you really use this to document the Musculoskeleton system??? Physician is questioning since a muscle is supple then he can use this as Muscolo, instead of Neck, which is a body area. Can I have some opinions??:rolleyes:
 

LLovett

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I would count this as MS. Since they actually state "supple" that indicates it was related to the MS system. If they state something like "Neck-WNL" I would only count it as a body area.

Lovely shades of gray...

Laura, CPC, CPMA, CEMC
 

rossirob001

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Thank you! Now, for MDM if physician states ECG reviewed by me - I would only count this as 1 data point since he did not state "my read" or "read by me". Would you agree??
 

LLovett

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Generally yes I would agree with you but it may depend on the situation.

I have scenarios where the cardiologist doing the over read does not read the ekg for several days after it is done. In those cases the provider that ordered had to to do their own interpretation because there wasn't any other to review.

Laura, CPC, CPMA, CEMC
 
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