Forum - Questions & Answers

Jun 6th, 2015 - lkclayton75 2 

counting organ system vs body area

I need some help on counting my organ system. The way our EMR is set up it lets the provider pick body area and organ system so I have to weed out the body area. My provider says I can use both.

Example: Neck: supple and no lymphadenopathy.

Lungs: Auscultation: no wheezing, rales/crackles, rhonchi, tachypnea, or retractions and clear to auscultation


She says I can use neck because the lymphnodes are being referred to. I can count lungs as resp. Can I do this? I have never accepted this in the past and if I'm doing this wrong please tell me.

Thanks for the help!

Jun 9th, 2015 -

re: counting organ system vs body area

your provider is correct, per the 1997 guidelines and the E&M documentation auditor's instrucitons you can use the body area as one bullet and the organ system as another bullet. I would advise you to google the 1997 E&M documentation guidelines and read up on them, you may be doing your providers a disjudgement by not knowing the guidelines correctly.

Jun 9th, 2015 -

re: counting organ system vs body area

Here is also some information I found on this site. Try using the "Look it Up" section of the site, you may found alot of your answers before you even ask:)


There are a lot of articles in Codapedia about auditing:
http://codapedia.com/article_140_Auditing-the-exam-1995-Guidelines.cfm

http://codapedia.com/article_87_Review-of-Systems.cfm

http://codapedia.com/article_128_Past-medical-family-and-social-history.cfm

This one by Jennifer Schmutz is good

http://codapedia.com/article_499_Elements-of-a-Complete-Medical-Record.cfm







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