We seem to be having a huge debate in the office on the way we coders score our E/M services. Maybe we are looking into this too deep but it sometimes depends between a 99213 vs 99214.
When a provider states something like Pulses: normal in all four extremities, would you count that as 1 element in the cardiovascular exam or as some believe, it is 4 different pulses so count it as 4 elements?
Same issue when provider states Respiratory: lungs clear bilaterally to A&P, is that 2 elements or 4 for both right and left lung?
Also, can you pull elements from anywhere in the exam to use in specific systems as long as not using that element twice? ex: provider lists extremities, no clubbing, cyanosis, deformity or edema. Can you take the clubbing, cyanosis and edema and use it with the 1 element that was under pulses as the 4 elements in Cardiovascular? The provider in this case already listed 4 elements under musculoskeletal so can what he states in "extremities" be used in cardio? The providers are always mixing systems and areas but we count in one or the other, never twice.
We all have different views on what to count when scoring. Any help appreciated.
When a provider states something like Pulses: normal in all four extremities, would you count that as 1 element in the cardiovascular exam or as some believe, it is 4 different pulses so count it as 4 elements?
Same issue when provider states Respiratory: lungs clear bilaterally to A&P, is that 2 elements or 4 for both right and left lung?
Also, can you pull elements from anywhere in the exam to use in specific systems as long as not using that element twice? ex: provider lists extremities, no clubbing, cyanosis, deformity or edema. Can you take the clubbing, cyanosis and edema and use it with the 1 element that was under pulses as the 4 elements in Cardiovascular? The provider in this case already listed 4 elements under musculoskeletal so can what he states in "extremities" be used in cardio? The providers are always mixing systems and areas but we count in one or the other, never twice.
We all have different views on what to count when scoring. Any help appreciated.