tci ED Coding & Reimbursement Alert - 2011 Issue 10

Reader Question: Assign Physical exam Organ System By Statement Context

Question: Using 1995 guidelines, in which organ system would this fall for a PE element? "Neck: Normal range of motion. Neck supple." Would you count this as Musculoskeletal. or Lymphatic?Answer: This common physical exam notation will not always be assigned to the same organ system. In general, proper allocation to a physical exam body area or organ system will depend upon the context in which the statement is made. The comment" neck supple", implies a musculosketal exam was being done, However, if the patient was being evaluated for a fever or swollen glands, this could be part...

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