E/M coding
Hey Anne,
I'm only coding student. Nevertheless, I will do my very best to help. Here is my understanding:
The Body Areas (BA) are more specific and are as follows:
1. Head (including face)
2. Neck
3. Chest (including breasts and axillae)
4. Abdomen
5. Genitalia, groin, buttocks
6. Back (including spine)
7. Each extremity (up to 4)
If there is any documentation about the physician/healthcare professional touching, observing, or listening to any of these body areas, we account for that under the exam.
For the exam, we combine the BA/OS total number to see if it falls under:
Problem-Focused: # of BA/OS = 1
Expanded Problem-Focused: # of BA/OS = 2-4 (limited)
Detailed: # of BA/OS = 2-7 (extended)
BUT, when we get to Comprehensive Exam, we only go by OS (organ systems) and don't account for any of the BAs. Comprehensive: # of OS = 8 or more.
There are times when I read: "Abdomen soft and tender, normal bowel sounds". With that sentence, I would actually check the box for Abdomen and check the box for Gastrointestinal because of the "normal bowel sounds", which goes beyond merely examining the abdomen.
Ideally, for the Physical Examination, the report is organized by body area and organ system. This of course makes a big difference for coders. But, some reports are not organized like this, as you probably already know. Then we have to dig deeper into the report.
I think E/M is probably one of the most challenging parts of coding. I find gray areas sometimes where a statement could fall under 1 or 2 organ systems and/or a BA. Here is one I thought about: "Patient has a severe, painful rash on his right arm." The severe pain part would go under ROS. But the rash would go under Integumentary (skin) for the OS under Exam. Then, I would also check the box for an extremity for the BA due to the specificity of right arm. I think this is reasonable because the doctor examined the extremity (R arm), and also the skin, so my understanding is we would account for both.
I've been studying E/M coding for the ER. I find the process of selecting those codes are much different than other E/M coding. I'd be happy to provide articles/resources about ER E/M coding if you'd like.
Hope this helps!
Sincerely,
Jacob