Wiki Exam - Body Areas vs Organ Systems

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chetubig001

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I am very confused with the Examination portion of the E/M. You can count Body Areas and Organ Systems. Why would I choose Muskuloskeletal as an OS and only get 1 point, when I can choose 4 extremeties in the BA section and get 4 points? OR, why I choose Abdomen for GI? Please help with clarification
 
1995 vs 1997 guidelines

This partly depends on whether you are using 1995 or 1997 guidelines; and whether you feel you need a comprehensive exam.

For 1995 you need 8 organ systems to have a comprehensive exam. So whether you examine one extremity or 4 you only get 1 "organ system."

For some practioners it is more advantageous to audit using 1995. For other practioners it is more advantageous to audit using a 1997 specialty exam.

You can use whichever is best for your practice. You can even change from note to note.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
We use 95 guidelines. So that is for a Comprehensive. What if I just have a EPF or a Detailed? For example, Physician examines:

Neck
Chest
Cardio
Resp
Const
Musk

Would that count as 6 elements? Can I combine and count both OS and BA to get to a level or service or only count either OS or BA only?
 
1995 exam

EPF Exam - Limited exam of the affected body area or organ system PLUS other symptomatic or related organ system(s).

Detailed Exam - Expanded exam of the affected body area or organ system PLUS other symptomatic or related organ system(s).

So if patient comes in with a complaint of "hurt left wrist."

EPF exam: Left wrist edema. No tingling in fingers.

DETAILED exam: 10 YO male in no apparent distress. Pleasant and cooperative with exam. Left wrist with pain (7/10) on movement; significant swelling as compared to right wrist; abrasions on left forearm and palm of hand. Grip strength diminshed on Left vs right. No tingling or numbness of fingers. No cyanosis. Shoulder ROM is WNL and without pain. Pulses equal in both upper extremities.

There are some guidelines that count the BA or OS to determine the level ... 2-4 = EPF / 5-7 = detailed. And yes, you can mix for the EPF and Detailed.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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FTessaBartels said:
EPF Exam - Limited exam of the affected body area or organ system PLUS other symptomatic or related organ system(s).

Detailed Exam - Expanded exam of the affected body area or organ system PLUS other symptomatic or related organ system(s).

So if patient comes in with a complaint of "hurt left wrist."

EPF exam: Left wrist edema. No tingling in fingers.

DETAILED exam: 10 YO male in no apparent distress. Pleasant and cooperative with exam. Left wrist with pain (7/10) on movement; significant swelling as compared to right wrist; abrasions on left forearm and palm of hand. Grip strength diminshed on Left vs right. No tingling or numbness of fingers. No cyanosis. Shoulder ROM is WNL and without pain. Pulses equal in both upper extremities.

There are some guidelines that count the BA or OS to determine the level ... 2-4 = EPF / 5-7 = detailed. And yes, you can mix for the EPF and Detailed.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Click to expand...

I truly believe without your help describing to me the difference in exp and detailed; I would not have passed the CEMC exam last year. I recall asking you the same question and I printed out your response and kept working at it until I finally completely understood.

Just wanted to say "thanks again" to you for all your insight and help on the forums!
 
Neck in 1995

chetubig001 said:
We use 95 guidelines. So that is for a Comprehensive. What if I just have a EPF or a Detailed? For example, Physician examines:

Neck
Chest
Cardio
Resp
Const
Musk

Would that count as 6 elements? Can I combine and count both OS and BA to get to a level or service or only count either OS or BA only?
Click to expand...

If you are using 1995 guidelines. What system are you assigning the Neck. I only see Neck under body areas. Thanks
 
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