Coding: New Scoring for Body Areas/Organs
Effective February 1, 2017 coders will begin using the following:
For new patients, 8 organ systems is still a comprehensive exam.
Established patients: This will be very important on your established level 4’s (Office/ED settings) and subsequent level 3’s (Inpatient/OBS setting).
Instead of needing 2-7 body areas/organ systems, you will now need to document 6-7 BODY AREAS/ORGAN SYSTEMS (Expanded documentation of the areas and/or systems examined; requires more than checklists; it needs to have normal/abnormal findings documented upon
For an expanded problem focused exam the requirement now is 2-5 BODY AREAS/ORGAN SYSTEMS (Minimal detail for areas and/or systems examined: check list type documentation without any expansion of findings).