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97 Documentation Guidelines

  1. #1
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    In the physical exam component in the 97 Documentation Guidelines, for the Cardiovascular system: one of the bullets states extremities for edema and/or varicosities. My documentation states: Extremities; Without clubbing, cyanosis, or edema.

    Would that count as a bullet in Cardiovascular or a bullet in Musculoskeletal, or both?

    Thanks,
    Kristen
    Kristen Richard, CPC

  2. #2
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    For the Cardiovascular exam this would count for Cardiovascular and Extremities, but not Musculoskeletal. According to the 97 guideliensExamination of "Extremieites for peripheral edema and/or varicosities" is one bullet under CV. Then "Inspection and palpation of digits and nails (e.g. clubbing, cyanosis, inflammation, petichiae, infections, Osler's nodes) is the only bullet required uner extremities.

    There are three bullets listed for MS, "Examinationof the back with notation of kyphosis or scoliosis", "Examination of gait with notation of ability to undergo exercise testing and or/participation in exercise program", "Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements.

    Doreen, CPC

  3. #3
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    Default Cardiovascular and Musculoskletal
    Cardiovascular bullet: extremities of edema and/or varicosities

    Musculoskeletal bullet: Inspection and/or palpation of digits (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infection, nodes)

    So I would give two bullets for your docmentation of : Extremities; Without clubbing, cyanosis, or edema.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
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    This is M/S if you are using the General multi system exam, if you are using the Cardiovascular guidelines it is extremities not M/S, so depends on if you are using General or specialty exam.

    Doreen, CPC

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