Wiki new coder needs opinion on E/M

[ggparker14]

I am a new coder and just want to make sure I am understanding coding of E/M cases. I had a case recently where a patient was being evaluated for a dog bite. On the ROS and the physical exam, should I be counting organ systems such as GI, GU and PSYCH for cases such as this or only the organ systems that might pertain to the each individual case. The physician says he checked the GI, GU and PSYCH organ systems on the ROS and physicial exam, but I had an auditor tell me that these organ systems did not pertain to a dog bite, so therefore, I would not be able to count them in my ROS or the physical exam. Just wanting to make sure I am accurate in what I can and can not count. Any opinions would be appreciated. Thanks.

 

[RebeccaWoodward*]

I can understand where the auditor is coming from but you can't assume that these systems aren't relevant; we're not clinicians. There may be logic behind the review/examination of these systems that may not be apparent to us. I would certainly query the physician if you don't feel comfortable crediting this documentation.