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Absent/Removed organs: do we credit bullets in the Physical Exam?
I need a CMS, AMA or other official reference source for the above question. I found an article in the Supercoder website stating: "If your physician examines a patient who has had an organ removed, you can still count that organ toward the physical exam or review of systems (ROS) in scoring the evaluation and management level, say experts." I’m looking for support on this policy.
I would appreciate if someone could provide a reference for crediting physical exam bullets for absent organs.
Thank you.
E/M Bullets on hands
I am a little confused.:confused: We have a hand surgeon in our office and I find it a little hard and confusing when trying to count my bullet points on his exam. Mostly confused when he states patient had intact FDS, FDP, AND EDC function to all digits or on physical examination patient is non-tender to FCR, ECRL, and ECRB.
The problem I am having is I have one coder explaining that by the doctor stating the FDS, FDP, and EDC is only one bullet point all together. Then I have another coder explaining to me it is consider three bullet points since they are individual.
So as you can see I am confused and hoping someone can help clarify whether each one is consider individual or if he is examining this that they are all together?
Please Help!! Any information would be very helpful!
Thank you,
Michelle