Muskoskeletal vs extremities

Kcronin1122

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Can anyone help me understand what the difference is on the exam findings for muskoskeletal and extremities. I'm having a hard time trying to figured out if when the doctor stays "extremities: symmetric without deformity, no edema/clubbing, cyanosis, skim warm well perfumed & dry to the touch with symmetrical 2+ radial & dorsalis pedis pulses" is this considered muskoskeletal?
Thanks
 

Kcronin1122

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70 BPM 18 RPM on 2 L of NC
Gen: Mr.**** is a ill appearing WD/WN middle aged African American male that appears his stated age who is in mild acute distress, exhibiting moderate pain with deep respiration, & moderate discomfort. The patient is A&O x 4, is cooperative throughout the interview with appropriate responses.
HEENT: NCAT, symmetrical facial features with appropriate expression of affect, anicteric conjunctiva without pallor, PERRLA, EOMI, no rhinorrhea, MMM
Pulm: Positive for accessory muscle use, speaking in full sentences, no audible wheezes on approach, rhonchi in the upper left & right lobes, no consolidation or rales appreciated
Cardio: No JVD or carotid bruits, RRR, normal S1 & S2, no click/murmur/rub/gallop
Abdomen: Non-distended obese, without voluntary or involutary guarding, bowel sounds present, nontender to light & deep palpation, no fluid wave
Extremities: Symmetric without deformity, no edema at this time, no clubbing/cyanosis, warm well perfused & dry to the touch with symmetrical 2+ radial & dorsalis pedis pulses
Neuro: CNII-XII grossly intact

How many organ systems are you counting? I am only counting 7
 
Last edited:

daedolos

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Sorry for delay. Had emergency coding session.

I counted 8 systems touched upon:

Pysch = cooperative with appropriate responses, a&o X4
Constitution = 70 BPM, ill-appearing, mild acute distress
ENT = symmetrical facial features, anicteric conjunctiva with pallor, no rhinorrhea
Neuro = CNII-XII grossly intact, speaking in full sentences
Musculo = Extremities section
Respiratory = no audible wheezes, rhonchi in the upper left & right lobes, no consolidation or rales appreciated
Cardio = radial & dorsalis pedis pulses, no JVD or carotid bruits, no click/murmur/rub/gallop
Gastro = non-distended obese, bowel sounds present

Peace
@_*
Wish the doctors here were this thorough with documentation.
 

jdibble

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Can anyone help me understand what the difference is on the exam findings for muskoskeletal and extremities. I'm having a hard time trying to figured out if when the doctor stays "extremities: symmetric without deformity, no edema/clubbing, cyanosis, skim warm well perfumed & dry to the touch with symmetrical 2+ radial & dorsalis pedis pulses" is this considered muskoskeletal?
Thanks
I also do see that there is documentation to support 8 systems. However, just take note that whether they state musculoskeletal or extremities as the heading it is what they document under there as to what can be counted. As in your example above, under extremities your doctor has documented not only Musculoskeletal (symmetric without deformity) he has also documented cardio (no edema/clubbing, cyanosis and 2+ radial & dorsalis pedis pulses) and integumentary (skim warm well perfumed & dry to the touch). If he had not mentioned the deformity than he would not have captured anything pertaining to musculoskeletal.

Unless he actually documents something about the MS system, such as deformities, range of motion, etc. you need to be careful as what other systems are referred to under the extremities heading.

Hope this clarifies this for you.
 

Kcronin1122

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Thanks Jodi, That is what i'm having a hard time understanding what is considered "muskoskeletal" I am fairly new at E/M coding so i'm just trying to learn as much as possible to make sure I feel confident in what I am looking for. Your reply is very helpful.
 

Kcronin1122

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So in this exam it says
Extremities: normal, a traumatic, no cynosis or edema, no ulcers.

Would this be considered "muskoskeletal" or just extremities
 

Kris Cuddy

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I found looking at what constitutes musculoskeletal in the 1997 documentation guidelines was a great help for me.

Also using the Anatomy Coloring Book was very helpful when I took anatomy and physiology. You can buy one here: https://www.barnesandnoble.com/w/the-anatomy-coloring-book-wynn-kapit/1125545034?ean=9780321832016&pcta=n&st=PLA&sid=BNB_DRS_Core+Catch-All,+Low_00000000&2sid=Google_&sourceId=PLGoP79700

PubMed has a good definition and description, found here: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0027058/

You can also register for a free account and use KenHub. It's a great resource, found at: https://www.kenhub.com/en/dashboard

I think one of the things that confuses people is the labels of examination area in a note. A provider might document at neck to the effect of supple; which does equate to the body area of neck. Another might document at neck to the effect of No LAD; which equates to the body organ system of lymph.

You'll need to decide which best suits the provider whether it be the body area of the extremities, or whether you separate it out into the body organ systems that were examined within the extremities.

I hope this helps.
 
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