Exam: Counting Body Areas & Organ Systems

acw

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I have been taught that for the expanded and detailed exam portion of an E/M visit that you can total the count of both organ systems and body areas with no "double-dipping"; however, for Comprehensive it is 8+ organ systems only. I have a coder telling me that she has been taught for expanded and detailed exam you can count either body area or organ system, but not both. On page 9 of the CMS/AMA Guidelines for Documentation of Examination: Expanded Problem Focused states, " ...limited examination of the affected body area or organ system and other symptomatic or related organ system(s)." For Detailed states, "...extended examination of the affected body area(s) and other symptomatic or related organ system(s). My questions is: Do we still count affected body areas and organ sytems in expanded and detailed, or do we only count one or the other now?
acw
 

Walker22

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The 1997 E&M guidelines haven't changed. For a comprehensive exam you must examine at least nine organ sytems OR body areas. The exact bullet points that must be documented in each system are specifically outlined in these guidelines. Get yourself a copy from the CMS website, it spells it all out for you in great detail!
 
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Milwaukee WI
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1995 guidelines

1995 guidelines are VERY vague (as you have noticed).

We count BOTH organ systems and/or body areas for exams that are NOT comprehensive. (Only organ systems for the comprehensive exam.)

The important thing is to have a policy in place in your office as to how you apply the guidelines and STICK to that policy. Any auditor's first question will be to ask for your internal policies and procedures.

You cannot defend inconsistency.

F Tessa Bartels, CPC, CEMC
 

acw

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St Peter, MN
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Thank you Tessa! Your answer was clear and consise. I thought the same, was going to make an internal policy. So glad others think like me. When someone challenges the E/M guidelines, I seem to second-guess myself, even when I know the answer, and it is always nice to know that other coders have the same answers and nice to have them verified. Take care, Annette
 
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