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Charlene Posted Thu 19th of November, 2015 14:53:35 PM

I'm not as comfortable with 1995 guidelines as I feel they are too vague. Since the 1995 exam is divided by 7 body areas and 12 organ systems, and the definition of a comprehensive general multi system exam includes at least 8 organ systems.

What is the difference between the exam of abdomen as a body area and a GI organ system or examining the bilateral lower extremities and musculoskeletal system?

SuperCoder Answered Mon 23rd of November, 2015 02:02:15 AM

The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems. There is a dotted line between the body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems you would be giving credit twice which would be incorrect when determining the final score for the examination section of the score sheet.

An example could be: the documentation in the patient's medical record stated, abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under GI which ever area benefited the physician the most.

Charlene Posted Mon 06th of June, 2016 14:58:10 PM
I've read somewhere that a Medicare auditor would expect at least TWO findings documented for each of the eight systems to meet comprehensive 1995 exam. Since the 1995 guideline is vague in this regard, do you have recommendation or other evidence?
SuperCoder Answered Tue 07th of June, 2016 02:31:46 AM
The query was posted 1 year ago with no response heard from yourside. Please post your query in new thread.

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