Wiki Do you count hips as part of Spine/ Ribs/ Pelvis or Lower Extremity in an audit?

[abfloyd1]

In particular, I'm auditing spinal exams where the hip is palpated and ROM taken as part of a lumbar spine exam for back pain. In this case, I would assume it is considered part of the spine body area- Right? If the doctor was examining the lower leg, and doing the same thing, I would consider it lower extremity body area. Should I be "crediting" lower extremity even in the case of a spine exam?

 

[Patricia Seabolt]

I would want to querry the provider to determine the reason he is performing this part of the exam.

If using 95 guidelines, you would need to know from the provider if this exam element is to evaluate the the affected body area
or organ system only or if the ROM is to evaluate other symptomatic or related organ system(s) based on the providers clinical judgement and history components.

If using the 97 guidelines, in the musculoskeletal system listed in the general multi-specialty exam shows spine, ribs and pelvis to be one area:

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf



Hope this helps,