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Physical Exam question

  1. #1
    Default Physical Exam question
    Medical Coding Books
    Orthopedic doctor states in physical exam portion of note: "patient is neurovascularly intact in the lower extremities." How many and which bullets would this statement cover?
    (We usually use 1997 Musculoskeletal Exam Guidelines for audit purposes.)
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group

  2. #2
    Milwaukee WI
    Default Neuro one bullet
    The use of the word "neurovascular" makes me think all that is being examined is sensation in the lower extremities. So I would give a credit only for Neuro bullet
    * Exam of sensation (e.g. by touch, pin, bivration, proprioception).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    I agree with F Tessa. I would only count as neuro. He did not say anything about the extremities "themselves". Just my opinion.

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