acw
Networker
I have been taught that for the expanded and detailed exam portion of an E/M visit that you can total the count of both organ systems and body areas with no "double-dipping"; however, for Comprehensive it is 8+ organ systems only. I have a coder telling me that she has been taught for expanded and detailed exam you can count either body area or organ system, but not both. On page 9 of the CMS/AMA Guidelines for Documentation of Examination: Expanded Problem Focused states, " ...limited examination of the affected body area or organ system and other symptomatic or related organ system(s)." For Detailed states, "...extended examination of the affected body area(s) and other symptomatic or related organ system(s). My questions is: Do we still count affected body areas and organ sytems in expanded and detailed, or do we only count one or the other now?
acw
acw