# Counting Body Area and Systems 95



## medicalsec (Apr 18, 2010)

I know that you can count both body systems and organ systems for the other levels that are not comprehensive. I do use the 8 systems for comprehensive.  If I was trying to bill a 99243, and was trying to meet the 5-7 critieria would I use the doctors statement Head: Without trauma as a body area or would I fit in in the MS area. It seems like most of the body areas can be fit into a system. Sometimes he just examines the thyroid when he does the neck, so I am assuming that this would fall in the body area caterory.  Am I correct in thinking that most of these body areas can be converted into a system?

Thanks,

Dee


----------



## FTessaBartels (Apr 19, 2010)

*Affected BODY AREA*

One more time ... 

The 1995 guidelines for exams are as follows.

Problem focused - a limited examination of the *affected body area *or organ system.

EPF - a limited examination of the *affected body area *or organ system, AND other symptomatic or related organ system(s)

DETAILED - an extended examination of the *affected body area *or organ system, AND other symptomatic or related organ system(s)

You already have the comprehensive down - 8 or more organ systems. 

Note that technically you can have only the affected body area and ONE other related/symptomatic organ system examined and you can still qualify for a detailed exam ... IF ... big, red *IF* ... you have an *extended *exam of the *affected *body area.

So if the presenting problem (affected body area/organ system) is the head, then you *can* count the body area.  If the presenting problem is belly ache, you CANNOT count "head atraumatic" as a body area.  

Trauma isn't mentioned anywhere on the 1997 bullet points either.

It's very frustrating for those of us in Pediatrics because a very common "exam" of a baby is "head atraumatic, normocephalic, anterior fontanelle soft and flat" ... nowhere in the 1995 exam unless it's the baby came in with a bump on his head (but then it shouldn't be "atraumatic," should it?  S I G H).

Hope that helps.

F Tessa Bartels, CPC, CEMC

Hope that helps.


----------



## medicalsec (Apr 19, 2010)

Thanks much!

Dee


----------



## SCanterbury (Apr 20, 2010)

Body areas and systems can be used in the lower three levels of the exam.


----------



## SCanterbury (Apr 20, 2010)

I 'm trying to post a rationale for the above statement but the website locks up whenever I try to reply. Maybe this short message will go through.


----------

