Results 1 to 3 of 3

E/M Documentation Clarification Needed

  1. #1
    Default E/M Documentation Clarification Needed
    Medical Coding Books
    In the "Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals" on page 121 the requirements for a Comprehensive Examination states "should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, UNLESS SPECIFIC DIRECTIONS LIMIT THE CONTENT OF THE EXAMINATION. For each area/system, documentation of at least two elements identified by a bullet is expected."

    My question is what exactly is meant by "unless specific directions limit the content of the examination" and how should it be applied?

  2. #2
    These are the 97 Documentation Guidelines for the multi-system exam. See below where there are areas giving the examiner minimal requirements. In the lymphatic system, the instructions say:

    Palpation of lymph nodes in two or more areas:
    C Neck
    C Axillae
    C Groin
    C Other

    and in Musculoskeletal System, the examiner has the option of:

    Examination of joints, bones and muscles of one or more of the following six areas: 1) head
    and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right
    lower extremity; and 6) left lower extremity. The examination of a given area includes:

    And in Genitourinary, you have a male/female option.

  3. #3
    Thank you, Thank you, Thank you!!!

Similar Threads

  1. Clarification Needed
    By Melissa Harris CPC in forum Anesthesia
    Replies: 4
    Last Post: 08-22-2014, 10:18 PM
  2. Clarification needed
    By j-fowler57 in forum Gastroenterology
    Replies: 6
    Last Post: 10-23-2012, 01:54 PM
  3. clarification needed on 73721
    By kathydaniel in forum Orthopaedics
    Replies: 0
    Last Post: 06-22-2010, 08:13 AM

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.