# Musculoskeletal Exam Elements



## PVAzCPC (Apr 3, 2013)

I am confused on "Examination of the joints, bones, and muscles of one or more of the following six areas:" 

So, if the provider does an exam of each extremity (RU, LU, RL, LL) which may include 4 possible assessments, does each extremity count as a "bullet" and each assessment count as a bullet?  

So theoretically, one could end up with 16 bullets just for the "Examination of the joints, bones, and muscles of one or more of the following six areas:" ; Is that correct?

Thanks for opinions


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## kagal0816@verizon.net (Apr 3, 2013)

*E & M Scoresheet for Orthopaedics*

Hi, I found the below link on the American Academy of Orthopaedic Surgeons when I was new to the specialty.  This is a great article and also has a very useful E & M tool geared toward Orthopaedic physicians.  I use and hand out this tool during my education presentations to the physicians and they have really responded quite positively.  Here's the link:  http://www.aaos.org/news/aaosnow/jul10/managing2.asp.

I assume that you are using 1997 E&M guidelines.  Technically, examination of the extremities as you describe would constitute 16 bullets, but would medical necessity be met?  As few as 12 bullets could push the examination portion into the detailed level.  While I am sure that there are patients who present with problems that would make examination of RUE, RLE, LUE, and LLE necessary, this would not be the case "routinely".  History, physical examination and medical decision making requirements are not the only determinant when choosing a code. The overarching criteria when choosing an E & M level is medical necessity according to CMS.

But again, technically that is correct.  By examining another system (even 1 bullet) like psych, the physical examination component could be scored as detailed.  

The above is my understanding of the guidelines for evaluation and management services.  

Karen Gallagher, CPC, COSC


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## PVAzCPC (Apr 4, 2013)

Thank you, Karen, this is very helpful information and I really appreciate your time!  I would rarely use all 16 bullets, you are correct, medical necessity not usually there.  This is just one of those nagging questions that I has kept bugging me!  Now, maybe I can sleep at night!   Thanks again 



kagal0816@verizon.net said:


> Hi, I found the below link on the American Academy of Orthopaedic Surgeons when I was new to the specialty.  This is a great article and also has a very useful E & M tool geared toward Orthopaedic physicians.  I use and hand out this tool during my education presentations to the physicians and they have really responded quite positively.  Here's the link:  http://www.aaos.org/news/aaosnow/jul10/managing2.asp.
> 
> I assume that you are using 1997 E&M guidelines.  Technically, examination of the extremities as you describe would constitute 16 bullets, but would medical necessity be met?  As few as 12 bullets could push the examination portion into the detailed level.  While I am sure that there are patients who present with problems that would make examination of RUE, RLE, LUE, and LLE necessary, this would not be the case "routinely".  History, physical examination and medical decision making requirements are not the only determinant when choosing a code. The overarching criteria when choosing an E & M level is medical necessity according to CMS.
> 
> ...


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## MikeEnos (Apr 4, 2013)

Yes, each item identified by a bullet counts as 1 - so if they did an assessment of range of motion of the left upper extremity and muscle strenth of the left upper extremity, that's 2 points, and so on. 

Beware of arbitrarily deciding what aspects of the exam were medically necessary or not-- many of us are not clinicians, so avoid telling doctors that something they checked wasn't medically necessary.  They may have been looking for something that isn't obvious to you and me.


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## kagal0816@verizon.net (Apr 4, 2013)

*Medical Necessity*

Mike - Absolutely correct!  Medical necessity should be determined by the provider and should be documented clearly in the note. However, we must protect our clinicians, as well as our organization and if we note a provider billing high level visits for trigger finger (hypothetically) it is within our realm to speak with the provider.

It is inappropriate for any coder to alter codes submitted by the provider without discussion with the performing provider.  Usually when I present my case to my doctors, they end up agreeing.  Thanks, Karen


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## Dug94Jen (Apr 19, 2017)

*1997 Coding Guidelines*

Hi Karen,

I wondering if you would be able to email a copy of the AAOS article that you mention in your comment below, as when I clicked on the link it took me to an area on the AAOS website that requires a username and password. Unfortunately I do not belong to the AAOS.

I struggle with how to count the bullets in the physical exam for '979 guidelines. My email address is Jenny.Flint@cvmc.org
Thank you




kagal0816@verizon.net said:


> Hi, I found the below link on the American Academy of Orthopaedic Surgeons when I was new to the specialty.  This is a great article and also has a very useful E & M tool geared toward Orthopaedic physicians.  I use and hand out this tool during my education presentations to the physicians and they have really responded quite positively.  Here's the link:  http://www.aaos.org/news/aaosnow/jul10/managing2.asp.
> 
> I assume that you are using 1997 E&M guidelines.  Technically, examination of the extremities as you describe would constitute 16 bullets, but would medical necessity be met?  As few as 12 bullets could push the examination portion into the detailed level.  While I am sure that there are patients who present with problems that would make examination of RUE, RLE, LUE, and LLE necessary, this would not be the case "routinely".  History, physical examination and medical decision making requirements are not the only determinant when choosing a code. The overarching criteria when choosing an E & M level is medical necessity according to CMS.
> 
> ...


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## JillSmithers (Aug 2, 2017)

Dug94Jen said:


> Hi Karen,
> 
> I wondering if you would be able to email a copy of the AAOS article that you mention in your comment below, as when I clicked on the link it took me to an area on the AAOS website that requires a username and password. Unfortunately I do not belong to the AAOS.
> 
> ...



All you need to do is create an account, just like any other website. Then you can read all of the articles, and they are awesome!


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