Exam Components for E/M

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Dr. does a Physical Exam on his patients for these following areas:

General (Constitutional)
Head
Eyes
Ears, nose, mouth, throat
Extremities (Excluding a separate hand exam that he documents seperatly, below)
Neuro
Skin

He then usually does a Normal Wrist exam for Carpal Tunnel (He is a hand specialist) and list his detailed findings.
Please note: He does list his findings in his visit notes, for the above mentioned body areas.

My question is, can I count the separate hand exam that he does, as "Musculoskelatal" under Organ systems, or is it included in the "extremities" listed above?
 
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PE- extremities

My thought process is that it depends on what he bulleted out in the extremity exam- usually in extremities I am looking for edema, digital cyanosis, lymphadenopathy etc.
If he was checking for edema in the extremities and then goes to the Musculoskelatal to bullet out things like ventral aspect of writs, pain in fingers or in epicondylar region of elbow etc then I feel he would get credit for both.
 

thomas7331

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I'd urge caution here, as most E&M audit guidelines specify that you can count by either organ systems OR body areas, but not both. So in your example, I wouldn't count both Head and ENT as separate elements. Similarly, you could count the hand as one extremity, or musculoskeletal as the organ systems if that is what was examined on the hand, but not both.
 
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