I need to take this one a little further..........
Musculoskeletal Exam
Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
• Assessment of range of motion with notation of any pain, crepitation or contracture
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
• Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
My auditing software clearly allowes for each extremity to receive credit for ROM. Why would you only allow
1 point for reviewing the
ROM for upper LT/RT extremity
and lower LT/RT extremity? My software allows 4 points if all four extremities are examined.
Note 1: As a minimum, for a comprehensive exam all 4 bullets (Inspect/palpate, ROM, Stability, and Strength)in 4body areas and Skin in 4body areas in addition to all other exam elements noted above must be documented.
Note 2:
Documentation of multiple joints in the same body area is only 1 bullet for each descriptor (Inspect/palpate, ROM, Stability, Strength).
Example,
ROM of right shoulder, R elbow and R wrist is one bullet (I completely agree with this).
But, ROM R shoulder, L shoulder, R knee, L knee, neck, and back is 6
http://www.aaos.org/news/bulletin/may07/davidson_tables.pdf
The above reference is in fine print under the
Musculoskeletal ExamBullet Counter
**This is how I have always been taught by Orthopedic consultants as well as Medicare.**
The table in the first link is provided in this article (below link)
http://www.aaos.org/news/bulletin/may07/managing7.asp