# organ system vs. body area



## SONDRACIMINI (Mar 8, 2013)

Hi, I am studying for my CEMC certification. I am struggling with Organ System vs. Body Area. I seem to pick the wrong one when the dictation regards abdomen or neck. 

Here is my thought. Neck is a body area when examined for structure, it is a organ stystem (lymph) when examined for nodes etc. I am confused still on the abdomen and the head.

Can you help me?? I test tomorrow

Thank you


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## MikeEnos (Mar 8, 2013)

You have to consider what their finding is.  If they say something like "Abdomen: Normal Bowel Sounds" that is a gastrointestinal finding, so feel free to count it as such.  Just because they labeled it "Abdomen" instead of "GI" doesn't mean you as a coder are forced to count it as a body area instead of an organ system.


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## SONDRACIMINI (Mar 8, 2013)

*Still confused*

Thanks Mike for replying. So when the documentation say neck, supple....this is a BA?? But if the documentation says Neck no nodules this is a OS? Your help is much appreciated.


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## MikeEnos (Mar 8, 2013)

Well when the physician says "Neck: Supple" they are assessing the fact that the neck bends easily.  A stiff neck could be a sign of meningitis.  "Neck: No lymphadenopathy" is an assessment of the patient's lymph nodes.  If they mention BOTH of those things, they have 2 organ systems, so be sure to give credit!

Here's a few common findings for the neck, and the related organ system

Musculoskeletal- neck, full range of motion
Cardiovascular- neck, no jugular venous distention
Lymphatic- neck, no adenopathy
Neurological- neck, no stiffness or pain (meningitis)


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## SONDRACIMINI (Mar 8, 2013)

Got it. Thank you for you time. I was having a mental block of some kind and your broke through. Thanks again, Sondra


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## cnramsey (Nov 20, 2019)

MikeEnos said:


> Well when the physician says "Neck: Supple" they are assessing the fact that the neck bends easily.  A stiff neck could be a sign of meningitis.  "Neck: No lymphadenopathy" is an assessment of the patient's lymph nodes.  If they mention BOTH of those things, they have 2 organ systems, so be sure to give credit!
> 
> Here's a few common findings for the neck, and the related organ system
> 
> ...


Hi Mike 

I'm hoping you can help also with the neck for body vs organ. If my provider documents. Neck: Supple; No thyromegaly or nodules. Does this statement support OS?  I really struggle with this. Thank you


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## twizzle (Nov 20, 2019)

Good examples from Mike. I would also add that in the example for GI/abdomen, if the provider says 'soft, nontender' you would have to count that as a BA rather than an OS, the reason being that they are not really giving any OS detail by saying 'soft, nontender'. If they said 'bowel sounds active, no hepatosplenomegaly' then they are giving you info about that OS rather than the BA.
Hope this makes sense.


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