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ED Coding and Reimbursement Alert

Reader Question:

Assign Physical exam Organ System By Statement Context

Published on Tue Sep 20, 2011

Question: Using 1995 guidelines, in which organ system would this fall for a PE element? "Neck: Normal range of motion. Neck supple." Would you count this as Musculoskeletal. or Lymphatic?Answer: This common physical exam notation will not always be assigned to the same organ system. In general, proper allocation to a physical exam body area or organ system will depend upon the context in which the statement is made. The comment" neck supple", implies a musculosketal exam was being done, However, if the patient was being evaluated for a fever or swollen glands, this could be part of the lymphatic exam. And if the patient was being assessed for some other chief complaint such as fever and headache, it might be assigned to the neurologic system.
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