Part B Insider - 2012 Issue 5
Reader Question: Be alert when deciding which organ system match your physical exam elements
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Article Overview
This article addresses a documentation and coding question from emergency medicine involving how a routine exam statement may be interpreted for organ system review under the 1997 exam guidelines. It is intended for coders and clinicians who need to align charted exam elements with the appropriate body system context based on the clinical presentation and physician intent.
Why This Topic Matters
Accurate interpretation of exam documentation affects coding consistency and evaluation-and-management reporting in emergency medicine. The article helps readers understand the general issue of matching exam elements to the correct organ system under older guideline frameworks.
Article Sections
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Question
Introduces a coding/documentation question raised in an emergency medicine chart review scenario.
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Answer
Summarizes the general approach to interpreting the documented exam notation in context and references the applicable exam guideline framework.
What You Will Learn
- How documentation context can affect interpretation of an exam element
- How organ system assignment may vary based on the presenting problem
- How the 1997 examination guideline framework is discussed in relation to mental status documentation
- Why physician intent can matter when reviewing charted exam elements
Who Should Read This
- Medical coders
- Emergency medicine coders
- Compliance staff
- Clinicians documenting evaluation and management services
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