Wiki Need help coding w 1997 guidelines

[MMillercpc]

Im used to coding using the 1995 guidelines. As well I have been coding surgery for the last 5 years. I need a little boost to get started! Here's a scenario I need help with 1997 guidelines and 1995 so I can see the difference.....

A 16 y.o. patient presents to Dermatology Clinic for evaluation of itchy rashes of left elbow and knee. She was seen in the clinic 2 months previously for her acne condition. Complaint started a week ago after using a new soap product.

Physical Examination:
WDWN. N nails and hair. Itchy, dry, erythematous and scaly rash on the left elbow and left knee. No rashes noted on R elbow, R knee, chest, and back.

A/P: Atopic Eczema
Will prescribe corticosteroid cream, moisture frequently and avoid harsh soaps, detergent or solvents

DX code(s):

Assign the appropriate E/M code: Modifier(s):

CPT code(s):

 

[ringalls]

Hi
I have list the CMS guidelines link on the bottom

The difference between 95 vs. 97 is the exam.
95 exam
For purposes of examination, the following body areas are recognized:
• Head, including the face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity

For purposes of examination, the following organ systems are recognized:
• Constitutional (e.g., vital signs, general appearance)
• Eyes
• Ears, nose, mouth and throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/lymphatic/immunologic
97 exam
These types of examinations have been defined for general multi-system and the
following single organ systems:
• Cardiovascular
• Ears, Nose, Mouth and Throat
• Eyes
• Genitourinary (Female)
• Genitourinary (Male)
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin



A general multi-system examination or a single organ system examination may be
performed by any physician regardless of specialty. The type (general multi-system
or single organ system) and content of examination are selected by the examining
physician and are based upon clinical judgement, the patient's history, and the
nature of the presenting problem(s).
11
The content and documentation requirements for each type and level of examination
are summarized below and described in detail in tables beginning on page 13. In
the tables, organ systems and body areas recognized by CPT for purposes of
describing examinations are shown in the left column. The content, or individual
elements, of the examination pertaining to that body area or organ system are
identified by bullets (•) in the right column.
Parenthetical examples, “(eg, ...)�, have been used for clarification an

97 http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
95 http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf

please feel free to e-mail idf you have any question
rfitzgerld@yahoo.com
Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC

 

[MMillercpc]

WDWN. N nails and hair. Itchy, dry, erythematous and scaly rash on the left elbow and left knee. No rashes noted on R elbow, R knee, chest, and back.


So since there is no indication pf palpation of the skin, he would only get one bullet for the exam? Making it a problem focused exam?

 

[FTessaBartels]

Wdwn

Well developed/ well nourished (WDWN) would also count as one bullet under constitutional for 1997 or 1995 guidelines.

F Tessa Bartels, CPC, CEMC