Wiki Organ system and body areas

[Lynda Wetter]

Novitas gives the following instruction and example.
. Under the Examination Section of the 1995 Score sheet, can we combine the body areas and organ systems?

No. The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems. There is a dotted line between the body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems you would be giving credit twice which would be incorrect when determining the final score for the examination section of the score sheet. An example could be: the documentation in the patient's medical record stated, abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under Gastro Intestinal (GI) which ever area benefited the physician the most.


***My question is if an exam supports the head and back being examined and also supports respiratory, cardiovascular, constitutional.
Can those be added? So it would be either 3 or 5 exam points? I understand you cannot use GI and abdomen or each extremity and Musculoskeletal.

 

[Lynda Wetter]

Just found my answer in the Q& A section of there site

"Does the body areas of the examination section of the 1995 score sheet work exactly as the organ systems?

You may count up to 7 body areas or 7 organ systems for an expanded problem focused or detailed examination and you may count 8 body areas or 8 organ systems for a comprehensive examination. However, you may not add body areas and organ systems together to determine the level of the examination."

 

[bethlhunt]

Still not understanding

Just found my answer in the Q& A section of there site

"Does the body areas of the examination section of the 1995 score sheet work exactly as the organ systems?

You may count up to 7 body areas or 7 organ systems for an expanded problem focused or detailed examination and you may count 8 body areas or 8 organ systems for a comprehensive examination. However, you may not add body areas and organ systems together to determine the level of the examination."

I thought that with the 1995 Guidelines you could only have a minimum of 8 Organ Systems examined (NO Body Areas counted) for a Comprehensive Physical Examination,

but I thought that when using the 1995 guidelines for a PF, EPF, or Detailed Exam, you could use both Body Areas and Organ Systems to tally as long as there is NO overlap and NO double-dipping. You either count an item under Body Areas (i.e. abdominal tenderness / pain) as a Body Area item (abdomen) OR as an Organ System item(gastrointestinal). You cannot count the same item twice. You count it as one or the other. Right? But you can count neck and back along with cardiovascular and gastrointestinal and get 4 points for the 2 body areas plus the 2 organ systems you assessed on the physical exam, right? (when using the 1995 guidelines) Thanks