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Single Organ system Exam

  1. Default Single Organ system Exam
    Medical Coding Books
    I have a provider who only doing a single organ system exam based upon the patient's medical necessity:

    Here are the following elements he reviews for the patient
    Palpation of heart
    Ausculation
    Meaurement of blood pressure in the aortic and vertbral artery
    Examines
    Pedal Pulses
    Femoral
    Carotid
    Abdominal
    peripheral edema

    He will take vitals always and if necessary may check eyes or listen to lungs.

    Some people in my group would only give him a detailed exam, but I feel that it meets the single organ system requirments since he does this all of the time and based upon the type of patient that he is seeing.

    Has anyone else coding for a single system exam this way?

    Thanks

  2. #2
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    Milwaukee WI
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    Default 1995 vs 1997 single system
    If you are using 1995 guidelines AND he at least has vitals or respiratory/lungs in addition to this full cardiac exam you have a detailed exam (definition: an extended exam of the affected organ system/body area plus other related organ systems)

    To get a comprehensive exam on 1995 guidelines you need to document exam of at least 8 (out of 12) organ systems.

    If you are using 1997 general multi-system exam you have:7 bullets = EPF exam. (not counting the "extras" he sometimes does)

    If you are using 1997 CV specialty exam you have: 7 bullets = EPF exam (again, not counting the 'extras' he sometimes does)

    Google the 1997 E/M guidelines and then look through to find the Cardiovascular exam. You'll see that to get a comprehensive CV exam you need to document ALL the bullet points in the shaded areas, and at least one element in each of the unshaded areas. So you would need (In addition to what you say he always does):
    * any THREE of the following vital signs: sitting or standing BP; supine BP; pulse rate & regularity; respiration; temp; height;weight (3 vitals gets you ONE bullet point)
    * general appearance of the patient
    * Assessment of respiratory effort
    * auscultation of lungs
    * exam of abdomen w/ notation of masses or tenderness
    * exam of liver and spleen
    * obtain stool sample for occult blood for patients being considered for throbolytic or anticoagulant therapy
    * brief assessment of mental status, including
    - orientation to time place and person
    - mood and affect
    ALSO would need at least one bullet from each of the following areas:
    Eyes
    ENT
    Neck
    Musculoskeletal
    Extremities
    Skin

    To get a comprehensive general multi-system exam on 1997 guidelines, you need to have documented 2 bullet points from each of 9 different systems.

    I don't see any way you'll get to comprehensive exam with the type of documentation you've indicated this physician provides.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default Any additional information about the 1995 single organ system exam?
    I have never coded/audited by the 1995 single organ system exam, but it is something that has been recently discussed. I am somewhat skeptical since it seems to be so vague and there is no clear definition of what a "complete exam of a single organ system" is defined by. (Outside 1997 guidelines) CMS has it listed as an option but does not clarify or give any information about the requirements. It is my understanding it is acceptable to use this guideline, but it is usually accompanied by a policy that defines what that is for that physician or specialty group.


    Have you had any luck discovering any new information about this topic?

    Thanks!



    Quote Originally Posted by Travelgirl View Post
    I have a provider who only doing a single organ system exam based upon the patient's medical necessity:

    Here are the following elements he reviews for the patient
    Palpation of heart
    Ausculation
    Meaurement of blood pressure in the aortic and vertbral artery
    Examines
    Pedal Pulses
    Femoral
    Carotid
    Abdominal
    peripheral edema

    He will take vitals always and if necessary may check eyes or listen to lungs.

    Some people in my group would only give him a detailed exam, but I feel that it meets the single organ system requirments since he does this all of the time and based upon the type of patient that he is seeing.

    Has anyone else coding for a single system exam this way?

    Thanks

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