# This again...



## btadlock1

Yes, I'm still on the same issue I've been on for a while now...To give a bullet, or not to give a bullet...that is the question!  (I'll learn this eventually, I promise...)

So here are some phrases I'm having trouble deciding if/where to allow credit under 1997 guidelines. (I can't use 1995, so it's not really relevant here...) Please let me know what you think!

(Eye) "Extraocular movements intact" (I know I've asked on this one before, and I think the concensus was that it doesn't count, but now I'm not sure...)
"No chest wall tenderness" - This was under Respiratory, but would it count under M/S as examination of ribs?
(Under Neurologic) "Normal motor function. No focal defects" - This is just my theory (after seeing it several times), but I_ think _that 'no focal *defects*' is actually supposed to say 'no focal *deficits*' - I usually see it paired with something like "Cranial nerves II-XII grossly intact", but sometimes it's by itself. (Outside of that context, though, I guess he could just as easily be referring to their attention span...See - this is how I confuse myself...)
(Under CV) "Good pulses equal in all extremities." - Pedal pulses, maybe?
(Under GI) "Non-distended" - is it too much of a reach to count this as an examination of liver/spleen? Sometimes I'll see it with "no organomegaly", but not always...Isn't abdominal distention typically associated with liver/spleen problems? I don't want to nit-pick, but does it have to be more specific than "non-distended" to count for anything? (aside from examination of abdomen with notation of presence of masses/tenderness - that bullet had already been met elsewhere)


And one more question...under 1997 guidelines, as most of you know, there are the single-OS exams, and the general multi-system exam. All of the guidance I've been able to find says that the single OS exams were designed for specialists, but that anyone can use them. What I *can't* seem to find, is whether you can use bullet criteria from a Single OS exam _with_ the Multi-system exam...
Some of the bullets that I think my providers are going for aren't on the multi-system exam, but they are scattered throughout the single OS bullets. How does that work? Can I mix and match with the multi-system exam, or is it strictly "what you see is what you get", with the bullets available?

For example: I've got the phrase "Speech clear and coherent. Functional cognition intact."
Under the Single OS Psychiatric exam, that's worth 2 bullets - Description of speech, and description of thought processes. Those bullets don't exist under the Multi-system exam. Can I still count them???


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## Sandy Stevens

1997 -
Yes - your providers are using bullets from both, multi and single OS. Single OS exams were designed for specialists. IM is a specialty. We can see that counting exam bullets vary between the multi-system and single-system, even though exam type is no limited to a specialty.  

Counting the bullets in your question:  
-EOM exam (Eye and Neuro): x 1 bullet
- "pulses equal in all extremities" (multi and CV): -> is pedal pulses = x 1 bullet
"Non-distended" distention means enlargement = -megaly (multi; no single OS): x 1 bullet
"No chest wall tenderness" (M/S): x 1 bullet
"no focal deficit" *(multi and neuro): Exam of focal function include: 2nd cranial nerve (eg, visual acuity, visual fields, fundi); 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements); 5th cranial nerve (eg, facial sensation, corneal reflexes); 7th cranial nerve (eg, facial symmetry, strength); 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub); 9th cranial nerve (eg, spontaneous or reflex palate movement); 11th cranial nerve (eg, shoulder shrug strength); 12th cranial nerve (eg, tongue protrusion)Language difficulties = x 8 bullets (1997 counts 3rd, 4th and 6th cranial nerves as 1 bullet )  -> Single OS Neuro =  x 8 bullets; General multi-system = x 1 bullet


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## btadlock1

Sandra K Stevens said:


> 1997 -
> Yes - your providers are using bullets from both, multi and single OS. Single OS exams were designed for specialists. IM is a specialty. We can see that counting exam bullets vary between the multi-system and single-system, even though exam type is no limited to a specialty.
> 
> Counting the bullets in your question:
> -EOM exam (Eye and Neuro): x 1 bullet
> - "pulses equal in all extremities" (multi and CV): -> is pedal pulses = x 1 bullet
> "Non-distended" distention means enlargement = -megaly (multi; no single OS): x 1 bullet
> "No chest wall tenderness" (M/S): x 1 bullet
> "no focal deficit" *(multi and neuro): Exam of focal function include: 2nd cranial nerve (eg, visual acuity, visual fields, fundi); 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements); 5th cranial nerve (eg, facial sensation, corneal reflexes); 7th cranial nerve (eg, facial symmetry, strength); 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub); 9th cranial nerve (eg, spontaneous or reflex palate movement); 11th cranial nerve (eg, shoulder shrug strength); 12th cranial nerve (eg, tongue protrusion)Language difficulties = x 8 bullets (1997 counts 3rd, 4th and 6th cranial nerves as 1 bullet )  -> Single OS Neuro =  x 8 bullets; General multi-system = x 1 bullet



Okay, but is it acceptable to count bullets that only exist on a single organ system exam, if I'm actually scoring the exam based on the multi-system exam? It's not that they're really performing the single system exam in its entirety - they're trying to do a multi-system exam; the bullets for some of the things that they have documented just happen to be located on single OS exams. Can I count bullets from a single OS when using the multi-system exam? Thanks!


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## Sandy Stevens

To some degree (little) I used both. Let me explain. I audit 11 specialties. So when I'm auditing an ophthalmologist I use Eye, a neurologist - Neuro, behavioral health - Psych, etc, because the exam content is usually (though must be determined during audit), the type of exam performed. However, and no matter the specialty, if the physician/NPP is not performing a specialty-specific (single-system) exam, I use multi-system. For example, I count x 1 bullet for EOM whether it's an IM or ophth physician. There are other examples of this. So that's what I mean to "some", "little" degree. In other words, I don't "explode", per se, a cranial if a the single-system neuro exam is not being performed, no matter the specialty. If neurologist notes EOM examined I count that as x1 bullet. See?


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## FTessaBartels

*Stick to one*

Brandi,
I know I have answered this question before.

When auditing a note
1) audit using the multi-system general exam 
=OR=
2) audit using the specialty exam

NO, you cannot count bullets that exist ONLY on the specialty exam as part of your multi-system exam.

Hope that's clear.

F Tessa Bartels, CPC, CEMC


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## Sandy Stevens

That is clear. You should know.
That's what I will do from here forward.
Thank you Tessa.

ss


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## btadlock1

FTessaBartels said:


> Brandi,
> I know I have answered this question before.
> 
> When auditing a note
> 1) audit using the multi-system general exam
> =OR=
> 2) audit using the specialty exam
> 
> NO, you cannot count bullets that exist ONLY on the specialty exam as part of your multi-system exam.
> 
> Hope that's clear.
> 
> F Tessa Bartels, CPC, CEMC



Crystal clear!

I had actually posted this thread before the one that you answered me on - I trusted you the first time, I promise! 

Thank you both for your help!


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