Wiki 1995 E/M Guidelines

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dcraven

dcraven

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In the exam under the 1995 Guidelines if the provider has documented the following:
Neck: supple, no adenopathy, thyroid is normal

What are the thoughts on being able to pull "no adenopathy" as the Lymphatic system exam?
I know that 1997 requires at least 2 lymph areas to be documented, but 1995 does not give any guidance.

Also if you have no clubbing and no cyanosis documented - where would you give credit besides cardio and musculoskeletal?
 
body areas vs organ systems

When using 1995 guidelines, where I give credit depends on whether I am strictly assessing for the highlest level E&M (where I need ORGAN systems only), or for a level that might allow me to combine organ systems and body areas.

For the examples you gave

1) "no adenopathy" - I would count as exam of the lymphatic system OR exam of neck (body area)

2) "no clubbing or cyanosis" - Cardiovascular or musculoskeletal organ systems -OR- extremity (body area)


Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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