Wiki Please help! Is credit giving for the right and the left?

[valerie2424]

Medical Report reads:
Objective Findings: The right wrist shows mild swelling over dorsum and the radial aspect on the right side. Extension is 80% compared to the left. Flexion is 80%. Ulnar and radial deviation is full compared to the left. There is tenderness to the radial aspect and a positive Finkelstein's"

For evaluation and management, would you count both right and left extremities?

Thank you in advance for your help

 

[LLovett]

Depends on the exam you are using.

1995 body areas, yes. 1995 organ systems, no.

https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/95Docguidelines.pdf

1997 yes.

https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[valerie2424]

Thank you for your feedback and information. For further clarification if there are no findings when they state "compared to the left" would you still give them credit as there is no documented detailed finding.

Another example "She has positive impingement testing and rotator cuff strength testing is 4/5 compared to the left." There are no details for the left, how would you credit in the 95 or 97? Is there a specific guideline?

Thank you again for your help, I really appreciate the input.