Under the Examination Section of the 1995 Scoresheet, can we combine the body areas and organ systems?
No. The examination section of the 1995 scoresheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient’s medical record you can use either the body areas or the organ systems. There is a dotted line between the body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems you would be giving credit twice which would be incorrect when determining the final score for the examination section of the scoresheet. An example could be: the documentation in the patient’s medical record stated, abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under GI which ever area benefited the physician the most.
