Documentation
Guidelines for Evaluation and Management Services
American
Medical Association
Health Care Financing Administration
May, 1997
System /Body
Area:
Musculoskeletal
- Examination
of gait and station:Examination of joint(s), bone(s) and muscle(s)
/ tendon of four of the following six areas: 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.
The examination
of a given area includes:
- Inspection,
percussion and / or palpation with notation of any misalignment,
asymmetry, crepitation, defects, tenderness, masses or effusions.
- Assessment
of range of motion with notation of any pain (e.g., straight
leg raising), crepitation or contracture
- Assessment
of stability with notation of any dislocation (luxation), subluxation
or laxity.
- Assessment
of muscle strength and tone (e.g., flaccid, cog wheel,
spastic) with notation of any atrophy or abnormal movements.
NOTE:
For the comprehensive level of examination, all four of the elements
identified by a bullet must be performed and documented for each
of four anatomic areas. For the three lower levels of examination,
each element is counted separately for each body area. For example,
assessing range of motion in two extremities constitutes
two elements.
content and
Documentation Requirements
| Level
of exam |
Perform
and Document: |
| Problem
Focused |
One
to five elements identified by a bullet. |
| Expanded
Problem Focused |
At
least six elements identified by a bullet. |
| Detailed
|
At
least twelve elements identified by a bullet. |
| Comprehensive |
Perform
all elements identified by a bullet. |
HCFA
Documentation Guidelines
|
