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Bernadette10

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How many systems can be counted in this exam using 1995 guidelines? Thanks for any advice.

Alert, oriented x3. Obese.
Head: Nontender. No swelling or deformity.
Eyes: Perrla. Normal EOM, conjunctivae and lids.
Ears: Normal pinnas, canals, TMs.
Nose: Nasal sinus congestion.
Throat: Slight redness with exudate.
Mouth: Moist mucous membranes.
Neck: Nontender, FROM. No JVD.
Chest: Nontender. No retractions.
Lungs: CTA. No wheeze.
Heart: RRR. Normal S1, S2. No murmur or gallop.
Abdomen: Soft, Nontender.
Spine nontender. No swelling or deformity.
Musculoskeletal: Normal gait.
Lower extremities: No edema.
 
Bernadette10 said:
How many systems can be counted in this exam using 1995 guidelines? Thanks for any advice.

Alert, oriented x3. Obese.
Head: Nontender. No swelling or deformity.
Eyes: Perrla. Normal EOM, conjunctivae and lids.
Ears: Normal pinnas, canals, TMs.
Nose: Nasal sinus congestion.
Throat: Slight redness with exudate.
Mouth: Moist mucous membranes.
Neck: Nontender, FROM. No JVD.
Chest: Nontender. No retractions.
Lungs: CTA. No wheeze.
Heart: RRR. Normal S1, S2. No murmur or gallop.
Abdomen: Soft, Nontender.
Spine nontender. No swelling or deformity.
Musculoskeletal: Normal gait.
Lower extremities: No edema.
Click to expand...

I should have added to my question, can you use a combination of body areas and organ systems together when using 1995 guidelines? I would count this as 11 systems if this is allowed (constitutional, head, eyes, ENMT, neck, chest, respiratory, cardiovascular, GI, musculoskeletal, extremities). Or do you have to pick one or the other?
 
We can use the body area and organ systems together only up-to detailed exam however we can use only organ systems examination for comprehensive exam.
 
How many systems can be counted in this exam using 1995 guidelines? Thanks for any ad

If you are choosing to code for the physical exam prefer either body area or organ system,which is majorly supports the higher level. Here, if you go with organ system it supports for comprehensive.

1cons: Obese,
2.Eyes:perrla
3.ENT: Normal pinnas, nose, MMM
4.Musculo:Normal gait,No edema, neck non tender
5Cardio: RRR,JVD,edema
6.Resp: CTA
7.Lymphatic:TMs
8.Neuro:Normal gait
9.Psych: Alert, oriented x3

If you go with body area it supports detailed,

1.cons
2.head
3. neck
4. chest
5.extremities
6.Abdomen

for body areas- it leads the exam as detailed, there is no documentation for

7.Back
8.genitalia,groin, buttocks

to lead the exam of body area as comprehensive(8). We should never merge the body area and organ systems together to select the exam.

I Hope it will help you so,
Sathyaraj A
Medical auditor BCBS
 
sathyaraj said:
If you are choosing to code for the physical exam prefer either body area or organ system,which is majorly supports the higher level. Here, if you go with organ system it supports for comprehensive.

1cons: Obese,
2.Eyes:perrla
3.ENT: Normal pinnas, nose, MMM
4.Musculo:Normal gait,No edema, neck non tender
5Cardio: RRR,JVD,edema
6.Resp: CTA
7.Lymphatic:TMs
8.Neuro:Normal gait
9.Psych: Alert, oriented x3

If you go with body area it supports detailed,

1.cons
2.head
3. neck
4. chest
5.extremities
6.Abdomen

for body areas- it leads the exam as detailed, there is no documentation for

7.Back
8.genitalia,groin, buttocks

to lead the exam of body area as comprehensive(8). We should never merge the body area and organ systems together to select the exam.

I Hope it will help you so,
Sathyaraj A
Medical auditor BCBS
Click to expand...


Hi, I just want to clarify a couple statements in your response. In the beginning, counting elements in Organ Systems--for lymphatic, you listed TM's. What are you considering this to mean? The OP had it as part of ENT...I understood it to be tympanic membranes. Also, you listed normal gait under both MS and Neuro. This cannot be counted twice. My understanding is that typically, normal gait is considered a MS element.
 
Hi, I just want to clarify a couple statements in your response. In the beginning, co

Your statement is correct, TM's is a part of ENT exam. I thought that its seems like thyromegaly, so I counted lymphatic exam. and gait can count only one organ system, in musculoskeletal exam we have more than one element, we can consider gait as a part of neurological exam. Gait is normally defines as the pattern of movement of the limbs of animals, including humans, during 'locomotion' over a solid substrate.it is responsible for the nerve to control the movements. So we can consider gait as neurological system
 
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