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97 general multi system exam for musculoskeletal

  1. #1
    Default 97 general multi system exam for musculoskeletal
    Medical Coding Books
    Can someone help with this?

    Using the 97 E/M guidelines for general multi system exam under musculoskeletal it states one or more of 6 areas and it list upper exremity, lower extremity etc do we count each extremity separately if range of motion is checked on the left and right - would this count for 2 bullets?

    Thanks,
    Maria

  2. #2
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    North Carolina
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    If the physician documents that he checked RT and LT lower extremeties for ROM, I do credit both. It depends on the documentation. If the provider documents SLR (straight leg raise) ROM... I only count one since this is testing the ROM for the spine.

    Curious what others do........

  3. #3
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    Quote Originally Posted by rebeccawoodward View Post
    If the physician documents that he checked RT and LT lower extremeties for ROM, I do credit both. It depends on the documentation. If the provider documents SLR (straight leg raise) ROM... I only count one since this is testing the ROM for the spine.

    Curious what others do........
    I agree with Rebecca, I have actually never seen it documented as SLR, so thats new to me... and as I always say I learn something "new" everyday...

    Thanks for that tip.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4
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    You will see neurosugeons use this terminology. When I entered the neurosurgery world it felt like a foreign language.

  5. #5
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    Milwaukee WI
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    Default "One or More"
    Since the directive specifically states "one or more of the following six areas" I only give ONE bullet for checking range of motion ... whether they checked for just the UL extremity or checked all six areas.

    F Tessa Bartels, CPC, CEMC

  6. #6
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    I need to take this one a little further..........

    Musculoskeletal Exam

    Examination of gait and station

    Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

    Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:

    • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
    • Assessment of range of motion with notation of any pain, crepitation or contracture
    • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
    • Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

    My auditing software clearly allowes for each extremity to receive credit for ROM. Why would you only allow 1 point for reviewing the ROM for upper LT/RT extremity and lower LT/RT extremity? My software allows 4 points if all four extremities are examined.

    Note 1: As a minimum, for a comprehensive exam all 4 bullets (Inspect/palpate, ROM, Stability, and Strength)in 4body areas and Skin in 4body areas in addition to all other exam elements noted above must be documented. Note 2: Documentation of multiple joints in the same body area is only 1 bullet for each descriptor (Inspect/palpate, ROM, Stability, Strength). Example, ROM of right shoulder, R elbow and R wrist is one bullet (I completely agree with this). But, ROM R shoulder, L shoulder, R knee, L knee, neck, and back is 6

    http://www.aaos.org/news/bulletin/ma...son_tables.pdf

    The above reference is in fine print under the Musculoskeletal ExamBullet Counter

    **This is how I have always been taught by Orthopedic consultants as well as Medicare.**

    The table in the first link is provided in this article (below link)

    http://www.aaos.org/news/bulletin/may07/managing7.asp
    Last edited by RebeccaWoodward*; 01-29-2009 at 01:55 PM.

  7. #7
    Default
    I agree with Rebecca.

    This area of exam is heavily weighted and they should get credit for all they are documenting.

    If you only give one element how could they ever get a comprehensive single system exam?

    Laura, CPC

  8. #8
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    Jacksonville, FL River City Chapter
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    There are explicit instructions in the musculoskeletal single-sytem exam to credit each of those four bullets separately for each of the six body areas mentioned.

    This instruction is not repeated in the general multi-system portion of the E/M guidelines, but is understood by most to apply there as well, as the musculskeletal system exam in both places is virtually identical.

    Seth Canterbury, CPC, ACS-EM

  9. #9
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    Milwaukee WI
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    Default I was referring to GENERAL multi-system
    I was referring to General Multi-system exam in my response. That's why I'd only give ONE bullet point for range of motion (as an example), even if ROM was tested on more than one extremity.

    F Tessa Bartels, CPC, CEMC

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