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1995 Exam Documentation

  1. #1
    Default 1995 Exam Documentation
    Medical Coding Books
    Will someone please clarify. Our office has always used 1997 guidelines, but I believe for some of our physicians/specialities it may be more beneficial to use 1995.

    On the exam portion. Is each body area counted separately as a system, or do you get one for all body areas? Also for comprehensive level can you consider a body area to count as musculoskeletal for organ system?

  2. #2
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    Daytona Beach, FL
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    Default
    For 95 guidelines you can either count body areas or systems. You can't combine them together, however you can interchange then. In other words, if the documentation shows an exam of the abdomen, you would either count that as 1 body area under abdomen, or you would use it as GI under the systems. As far as considering a body area for musculoskeletal, if the documentation under the extemeties refers to something in regards to musculoskeletal, such as range of motion, then you could use musculoskeletal. If under extremities it refers to pulses then that would be under cardiovascular.

    I use the body systems for 95 guidelines as it is easier to get to 8 systems for a comprehensive level.
    Jodi Dibble, CPC

  3. #3
    Location
    Milwaukee WI
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    4,466
    Default 1995 guidelines
    The 1995 guidelines identify 12 organ systems - For a comprehensive exam, you MUST document examination of at least 8 of these systems:
    1. Consitutional
    2. Eyes
    3. Ears, Nose, Mouth, Throat
    4. Cardiovascular
    5. Respiratory
    6. Gastrointestinal
    7. Genitourinary
    8. Musculoskeletal
    9. Skin
    10. Neurologic
    11. Psychiatric
    12. Hematologic / Lymphatic / Immunological

    You cannot use body areas for a comprehensive exam under the 1995 guidelines.

    F Tessa Bartels, CPC, CEMC

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