EM Coding Alert

Question: If the physician examines a patient who has had an organ removed, canyou can still countthat organ towards the physical exam or ROS in scoring the E/M level?

Texas Subscriber

Answer: Yes. A system is a system, not an organ. So, if you have a lung removed, you still have another one, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med Group in Pittsburgh. You also have a nose, pharynx, etc. If you have a kidney removed, or even both, you still most likely have a bladder, ureters, urethra, urostomy, etc.

“You have other organs within the system that might be very important toward the examination and the decision-making of the physician,” Hauptman says. “In fact, those systems might be more important because of the lack of one of the components.”