# Please audit this exam



## OliviaPrice (Apr 12, 2011)

If the physician documents:
Physical Exam
Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.

How many points would this be and what organ systems and/or body areas would you assign this to?


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## purplescarf23 (Apr 13, 2011)

I would count:
supple under Musculoskeletal
no JVD, no carotid bruits under Neck 
no lymphadenopathy under Lymphatic

3 total for an EPF exam

Hope that helps.

Kelsey, CPC


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## btadlock1 (Apr 13, 2011)

PRICEOR said:


> If the physician documents:
> Physical Exam
> Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.
> 
> How many points would this be and what organ systems and/or body areas would you assign this to?



I see these statements all of the time - I give it 3 bullets:

Supple is 'examination of neck' bullet
'No cartoid bruits' falls under a cardiovascular bullet
and 'no thyromegaly' is under neck, examination of thyroid. 

The jugular vein isn't listed as a bulleted exam element, so it gets no credit, and "no lymphadenopathy" is too vague to meet the minimum requirements of the lymphatic system's bullet, which requires the examination of at least 2 lymph node areas; the neck is only one.

Hope that helps!


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## OliviaPrice (Apr 14, 2011)

Thanks for responding!

I would normally give this statement credit for 3 systems/areas:
Neck - Supple, no thyromegaly
Cardiovascular - no JVD, no carotid bruits
Lymphatic - no lymphadenopathy 

But I recently received an opinion that if the doctor uses the heading "neck" you should only count that as 1 body area no matter what is said.

Any opinions on this??


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## btadlock1 (Apr 14, 2011)

PRICEOR said:


> Thanks for responding!
> 
> I would normally give this statement credit for 3 systems/areas:
> Neck - Supple, no thyromegaly
> ...



I don't agree with that - things are mislabeled in notes all of the time, and the doctor doesn't _have_ to label anything, really - I typically only use 1997 guidelines, but if you're going by 1995, then I'd say you've got it right!


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## OliviaPrice (Apr 14, 2011)

I agree!!  

Thanks!


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