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97 Physical Exam bullet: extremities

  1. #1
    Lewiston-Clarkston Chapter
    Default 97 Physical Exam bullet: extremities
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    Can someone help me know whether an exam bullet(s) for extremities can be counted in the example below.

    EXTREMITIES: External fetal monitor shows a fetal heart rate baseline of 135 with minimal to moderate variability and spontaneous variable and late deceleration's. External uterine monitor shows contractions randomly approximately every 10 minutes.

    Can a bullet be counted for the uterus contractions? what about the fetal heart rate and late deceleration's?

    This is obviously a pregnant patient, this is taken from the hospital HPI.


  2. #2
    This looks like the procedure note from two different monitors (unless the same machine was used to read both heart rate and contractions).

    I would be hard pressed to use any of the given documentation towards any of the specialty examinations provided by CMS, as I do not see any clear connection with the documentation and any exam elements given.

    If for Uterus, then the documentation should probably describe the health of the uterus in more detail.
    I see nothing applicable for the Fetal Heart Rate in any of the specialty examinations.

    The text might support some diagnostic radiology procedure code, depending on the rest of the note however.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

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