Wiki Exam Portion of E/M coding

[1formissy]

Just when I think I got it, now I dont! I have been following the Novitas 4x4 rule, when it comes to determining the Exam portion of the medical record. It was my understanding, that the record needs to be 4 body areas, OR 4 ogan systems, but not a combination of both.
For example,

Consititutional = 1
Eyes= 2
Cardiovascular= 3
Gastrointestinal= 4

To me, that would be a DETAILED exam. HOWEVER, say for example you see this in a record....

Constitutional=1
Neck= 0
back=0
Respiratory=1

To me, that would be a EXPANDED PROBLEM FOCUSED exam.

Am I looking at this wrong?

 

[jonesjoleta@gmail.com]

4x4 Rule

Hi Missy! There are some good examples on the AAPC Medical Coding & Billing Forums website - here is the link: https://www.aapc.com/memberarea/forums/printthread.php?t=87055 This is under "4x4 Rule for detailed exam. Hope this helps!

 

[cmartin_333]

The 4x4 rule for Novitas Solutions states the examination of 4 elements (findings) of at least 4 body areas or 4 organ systems.

Example:
Musculoskeletal: + ROM of all extremities, No deformities, No focal bony tenderness, Normal gait
GI: Abdomen soft, Normal BS, No organomegaly, + umbilical hernia
ENT: TMs: Intact, clear, no effusion Nares: Boggy Mucosa Oral Cavity: Moist, no ulcers or lesions Teeth: Normal dentation
Cardiovascular: Normal RRR, No Carotid Bruits, No JVD distention, No peripheral edema

I hope this helps!!!!

C.Mansuy, CPC, CEMC

 

[1formissy]

Thank you all for the information. It paint's a much clearer image for me, and a better understanding.

 

[Lynda Wetter]

Look at the link below, question #4 And # 16.

http://www.novitas-solutions.com/we...ntentId=00005056&_adf.ctrl-state=9xr9p2doj_75