Wiki 95 rules

[medicalsec]

I know that the neck is a body area, and if the doctor mentions no lymphadenopathy it could fit into the lymphatic system. The doctor often only states "supple" in this area. Am I correct in saying that he would not get credit for a system in this area. It would be counted as a body area?

Also, he always uses the category "extremities" and mentions (edema or lack of). I believe that this would go to the cardio area, but he also mentions "no calf tenderness" could that count toward the muscular area? They use the 95 rules. I always see examples of the 97 rules, but I can never seem to find good examples of the 95 exam rules. I sometimes have some gray areas in converting the body area categories into systems in order to meet the comprehensive critieria. Does anyone have a good reference site that shows examples of the 95 examination?

Thanks,

Dee

 

[FTessaBartels]

Use 1997

I use the 1997 guidelines to help me determine in which organ system a given statement falls EVEN when I am using the 1995 guidelines to arrive at the level of service.

So, yes "calf without tenderness" falls under musculoskeletal.

Hope that helps.

F Tessa Bartels, CPC, CEMC