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musculoskeletal template

  1. Default musculoskeletal template
    Medical Coding Books
    Does anybody know where I can find a musculoskeletal template. Im having a difficult time trying to identify where the bullets are. Im pretty good finding the body systems but not the bullets for example:
    Pt is a well developed male, appears his state age. lungs are clear to ausculation. Heart regular rate and rythm. extremities without edema, very limited range of motion in flexion, extension and lateral tenderness in the midline and paraspinal areas. Some SI joint and tochanteric bursa tenderness. has almost full flexion. but extension is extremely limited. He can hardly get to neutral extension. Upper and lower extremities with normal strength, sensation and deep tendon reflexes.

    I have :
    Constitution 1 pt
    respritory 1 pt
    Cardiovascular 1 pt
    Extremities without edema ??
    Upper and lower extremities with normal strength 1 pt
    neurologic- sensation and deep tendon reflexes 1 pt -
    I know I'm missing stuff, help

  2. #2
    you can get that template off of CMS's website in the 1997 guidelines.
    Debbie Potts England
    Lyles, TN 37098

  3. #3
    Manhattan, NY
    Try going to this link, The musculoskeletal bullet points begin on page 33 of the document. Bullet points for the other systems begin on page 14 of the document. I have printed a copy of the document, and keep it nearby when I'm auditing charts. Believe me, I refer to this document all the time!

  4. Default
    thank you everybody.

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