Coding Corner Answer: January Coding Challenge

1. Head and neck
2. Spine, ribs, and pelvis
3. Right upper extremity
4. Left upper extremity
5. Right lower extremity
6. Left lower extremity

Even though the physician is choosing to perform a musculoskeletal exam, documentation guidelines require the health professional to also examine and document the constitutional, cardiovascular, lymphatic, skin, and neurological/psychiatric systems.

Didn’t do so well on the quiz? Don’t feel bad—understanding the E/M documentation guidelines is a complicated process and sometimes causes confusion even among seasoned coders. To see the full description of both the 1995 and 1997 documentation guidelines visit, www.cms.gov under evaluation and examination. For rheumatology-specific coding information, download your free copy of the ACR’s Rheumatology Coding Manual. Visit www.rheumatology.org/publications and click on “Practice Management Publications” to get your copy.

If you have questions or need more information on the auditing process, contact Melesia Tillman, CPC-I, CRHC, CHA, at (404) 633-3777 ext. 820 or [email protected].