ED Coding and Reimbursement Alert

Question: I'm looking for clarification of the exam portion of the 1995 E/M guidelines, which state that a comprehensive exam is comprised of eight or more organ systems. In terms of the abdomen and musculoskeletal organ systems, what differentiates the documentation required for a GI organ system from the abdomen body area? Also, how should I differentiate between the extremity body area and the musculoskeletal organ system?

Oregon Subscriber

Answer: The requirement for a comprehensive exam is at least eight organ systems, or a complete exam of body areas, although this is not further delineated and was adopted more for use by single-system specialists such as ophthalmologists. Organ systems are grouped by function; body areas are grouped by location. The one thing you shouldn't do is mix them together.

The GI organ system would in general refer to such things as deep tenderness, masses, bowel sounds, distension, hernias, rectal exam, and the liver, gallbladder and spleen. The abdomen body area could refer to these things but might also include abdominal wall bruising or tenderness, rashes, palpable aorta or enlarged uterus.