BA and OS located within the exam trisect of the document, I believe, are integrated to the same sect, and if the provider has documented that arthritic changes are present in both upper and lower extremities, I would classify that under muskoskeletal OS or BA extremity- one or the other- and if documented edema surrounding joints, check off integumentary OS. It is very uncommon for an educated medical director to omit the term gait in a dictation, but anything is possible. Physicains are usual taught to logically form an E/M dictation during their medical training. You must consider the context of the patient case: is the patient older or younger, how sever is the arthritic problem, is this the first, second, or third encounter for the problem. There are so many factors influencing level of service, the code could only really be determined by the geographical location and facility type guidelines; although the CMS 1995 or1997 guidelines illustrate a bureaucratic check list, it is really to difficult to say level of service just by reading your coding book scenario. 30 percent of the time the coding books are wrong—Depending on were you purchased the material. I found that out the hard way.
If you would like, I could email you an actual E/M document that exemplifies a real life exam encounter were the MD substantiates the exam trisect.
Chad Malek, CPC, CCA
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