AAPC - Back to school
Results 1 to 4 of 4

Thread: Exam: Counting Body Areas & Organ Systems

  1. #1
    Join Date
    Apr 2007

    Default Exam: Counting Body Areas & Organ Systems

    AAPC: Back to School
    I have been taught that for the expanded and detailed exam portion of an E/M visit that you can total the count of both organ systems and body areas with no "double-dipping"; however, for Comprehensive it is 8+ organ systems only. I have a coder telling me that she has been taught for expanded and detailed exam you can count either body area or organ system, but not both. On page 9 of the CMS/AMA Guidelines for Documentation of Examination: Expanded Problem Focused states, " ...limited examination of the affected body area or organ system and other symptomatic or related organ system(s)." For Detailed states, "...extended examination of the affected body area(s) and other symptomatic or related organ system(s). My questions is: Do we still count affected body areas and organ sytems in expanded and detailed, or do we only count one or the other now?

  2. #2
    Join Date
    Apr 2007
    Athens, Ga.


    The 1997 E&M guidelines haven't changed. For a comprehensive exam you must examine at least nine organ sytems OR body areas. The exact bullet points that must be documented in each system are specifically outlined in these guidelines. Get yourself a copy from the CMS website, it spells it all out for you in great detail!

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default 1995 guidelines

    1995 guidelines are VERY vague (as you have noticed).

    We count BOTH organ systems and/or body areas for exams that are NOT comprehensive. (Only organ systems for the comprehensive exam.)

    The important thing is to have a policy in place in your office as to how you apply the guidelines and STICK to that policy. Any auditor's first question will be to ask for your internal policies and procedures.

    You cannot defend inconsistency.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Join Date
    Apr 2007


    Thank you Tessa! Your answer was clear and consise. I thought the same, was going to make an internal policy. So glad others think like me. When someone challenges the E/M guidelines, I seem to second-guess myself, even when I know the answer, and it is always nice to know that other coders have the same answers and nice to have them verified. Take care, Annette

Similar Threads

  1. Organ systems vs. body areas
    By ncgirl in forum E/M
    Replies: 4
    Last Post: 05-19-2013, 09:23 AM
  2. 1995 Physical Exam Body areas and systems
    By Svirgilio in forum E/M
    Replies: 2
    Last Post: 05-09-2013, 08:58 AM
  3. Counting Systems and Body Areas 1995
    By medicalsec in forum E/M
    Replies: 9
    Last Post: 07-14-2011, 08:31 AM
  4. Exam - Body Areas vs Organ Systems
    By chetubig001 in forum Auditing General Discussion
    Replies: 6
    Last Post: 09-29-2010, 03:58 PM
  5. count body areas and organ systems
    By debaloia in forum Family Practice
    Replies: 15
    Last Post: 10-20-2009, 02:12 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.