Wiki elements under a general multi-system exam - 97

[Colliemom]

Musculoskeletal - visual overview of all four extremities is normal

While calculating the level for the physical exam, would you count this under body areas for the exam? Or do you think the documentation is not sufficient? If you found it sufficient, how many points would you give it? (ie - each extremity?)

 

[thomas7331]

I would not consider this sufficient since no exam findings are documented for the extremities. Per the CMS guidelines: "Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal” without elaboration is insufficient... A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)."

 

[Colliemom]

Hi - sorry about that, I was in too big of a hurry. he did state visual overview of all four extremities is normal