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Can each extremity be counted separately for 95 guidelines?

  1. #1
    Rose City (Portland, Oregon)
    Default Can each extremity be counted separately for 95 guidelines?
    Medical Coding Books
    If the ortho doc examines both legs, may I count extremity x 2? Meaning, I would have an expanded problem focused exam under 95 guidelines?

    Second question, if I count an exam of a leg as extremity and the documentation also states, "skin intact', may I count skin too or is it part of the extremity exam?

    Thanks a bunch!!!

  2. #2
    Not under 95, you can under 97 though.

    I would give credit for inspection of skin based on that statement.

    Laura, CPC, CEMC

  3. #3
    Rose City (Portland, Oregon)
    The CPT book shows that it is "each extremity". Wouldn't that mean one exam for each extremity examined/docu'd? I wouldn't count 4 for "MAE" though.

  4. #4
    Milwaukee WI
    Default 1995 Body Areas
    1995 exam guidelines for EPF exam are: "limited exam of affected body area or organ system, AND other related systems. "

    Under the definition of body areas we find
    1. Head/face
    2. Neck
    3. Chest, Breasts, Axillae
    4. Abdomen
    5. Genitalia, Groin, Buttocks
    6. Back, Spine
    7. EACH extremity

    So yes, you can count each extremity BUT ... you still need another related system. I suppose you might get away with counting the other extremity as a related musculoskeletal system if it's for comparison purposes. (e.g. complaint is right knee pain; and you check both LE for range of motion, swelling, bruising, etc).

    As to your second question, yes this would count as Skin. Consitutional, Cardiovascular or Neuro might also be possibilities that would routinely be examined in conjunction with extremity issues.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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