Wiki Single Organ System

[krssy70]

My speciality is Breast...How do I utilize the single organ system for the 1997 documentation guidelines for the Breast. Here is how my Exam would read:

Breasts: Breasts were examined in both the sitting and supine position. They are visually symmetric. There is no nipple discharge or retraction. There is no skin changes or dimpling. On palpation, the right breast is soft and supple without any dominant masses. The left breast does have a dominant, subareolar mass that is firm to palpation, with slightly irregular margins. This is not tender to palpation. There is no axillary lymphadenopathy, bilaterally.

Please help..... I am not too familiar with utilizing the single organ system instead of the multi organ system.

thank you in advance for any input you may have,

 

[FTessaBartels]

1997 vs 1995

If you are going to use 1997 single system exam, breast fall under the Genitourinary system. (Yes, I know, the breasts are really part of the integumentary system.) And there is only ONE bullet given for "Inspection and palpation of breasts (e.g. masses or lumps, tenderness, symmetry, nipple dischrage)."

Since your examination will always be relatively focused on the this particular body area, I would advise you use the 1995 guidelines.

EPF exam: Limited exam of the affected body area or organ system, plus other related or symptomatic organ system(s)

Detailed Exam: Extended exam of the affected body area or organ system, plust other related or symptomatic organ system(s)

Speak with the physicians in your practice and determine the various "bullet points" that they would consider in an examination of the breats ... the exam you gave as an example has several (visual inspection, sitting and/or supine position, masses, nipples, skin, symmetry, tenderness, lymphadenopathy, etc). There may be others specifically related to postoperative examination. Have a policy/protocol in place in your office that states that a detailed exam is considered to be x bullets of the y total bullets. And stick to that guidance in determining if you have an EPF vs a Detailed exam.

Hope that helps.

F Tessa Bartels, CPC, CEMC