# Normocephalic under Organ Systems



## jdibble

Using the 95 guidelines and counting Organ systems, if the doctor only states Normocephalic, atraumatic, under HEENT exam - how would you count that?  Would you NOT count it towards the exam because he did not specifically mention anything about the eyes or ENT - or would you count both eyes and ENT since the statement implies everything with those systems is normal?

Thanks,


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## ajs

jdibble said:


> Using the 95 guidelines and counting Organ systems, if the doctor only states Normocephalic, atraumatic, under HEENT exam - how would you count that?  Would you NOT count it towards the exam because he did not specifically mention anything about the eyes or ENT - or would you count both eyes and ENT since the statement implies everything with those systems is normal?
> 
> Thanks,



There is nothing there to count towards eyes, ears, nose or throat.  The documentation is just stating that the head is of normal size and there are no injuries (atraumatic).  This only counts as Head.


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## jdibble

ajs said:


> There is nothing there to count towards eyes, ears, nose or throat.  The documentation is just stating that the head is of normal size and there are no injuries (atraumatic).  This only counts as Head.



Thanks Arlene - I am confused on this as I looked up the definition of Normocephalic and it states: 

"Normocephalic (literally translated means 'normal head') is a medical term referring to a person whose head and all major organs of the head are in a normal condition and without significant abnormalities."

Since the ENT and Eyes are major organs of the head, you would still say that this statement would not cover those Organ systems as being examined? 

Just making sure I have a complete understanding of how to apply this statement so that I can advise my doctors on any documentation improvements they may need to make!

Thanks again for all opinions!


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## LLovett

Normocephalic is musculoskeletal in my opinion.

The definition you list seems way to broad. Lets think about how many organ systems are present in the head area: skin, eyes, ent, neuro, cv, resp, lymph, and m/s. You could probably make the argument for more even. So what determines "major"? 

Are your providers trying to say they are lumping multiple systems in that one statement? I would ask them what they mean when they say that. If they feel they should be getting credit for multiple systems I would educate them to document more specifically and break it down into the different systems.

95 exam is not well defined. You are at the mercy of the auditor. All auditors have the potential to see things differently. The more clear and concise your documentation is the better it will fare in an audit situation. Documentation should not be about what you can get away with. It should paint a clear picture of the patients status and the work that the provider is doing. Then the coding should accurately represent what is shown in the documentation.

Laura, CPC, CPMA, CEMC


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## ajs

jdibble said:


> Thanks Arlene - I am confused on this as I looked up the definition of Normocephalic and it states:
> 
> "Normocephalic (literally translated means 'normal head') is a medical term referring to a person whose head and all major organs of the head are in a normal condition and without significant abnormalities."
> 
> Since the ENT and Eyes are major organs of the head, you would still say that this statement would not cover those Organ systems as being examined?
> 
> Just making sure I have a complete understanding of how to apply this statement so that I can advise my doctors on any documentation improvements they may need to make!
> 
> Thanks again for all opinions!



Interestingly enough, the Stedman's Medical Dictionary online takes "Normocephalic "and leads you to the synonym "Mesocephalic" and that definition is "Having a head of medium breadth, with a cephalic index between 76 and 80."  No mention of the other structures, so I would take that to mean normocephalic refers to the condition of the head itself only. 

Any other structures in the HEENT (which literally means Head, eyes, ears , nose and throat) have not been documented by stating "normocephalic".


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## MnTwins29

*Educating docs*

Since we use 95 guidelines in our reviews, I have instructed our docs to not use this term and instead break down exactly what areas were examined and are normal.   It has worked well.   That was the first time I have seen that word in months!


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## SuzanBerman

This term indeed refers to the head being of "normal" appearance. Although the MD mentions it under HEENT, it's important to "ignore" the heading that was used and read only the detail. 

You would have to count this only under the Head body area. If he further went into detail about the eyes, or ENT, then you could give credit appropriately.

I enjoyed reading this thread, it was very helpful.


Suzan Berman, CPC, CEMC, CEDC


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## jdibble

Thank you everyone for your input.  I think this makes it a bit clearer for me to present to my doctors so that they discontinue using this statement.  I didn't feel that this was sufficient enough for Eyes and ENT either, but I wanted some other opinions before I went back to the doctors.

As always everyone was very helpful!

Thanks,


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## schargis01

*new spin on  old topic*

I am now working with a group who considers Head: "Normocephalic" to be an examination of the neurologic system (??).  I disagree and have posed the question to CMS auditors in a few different AB MACS and have received the same response which is that it can only be counted as "head" in the body area category. However, I am still receiving push back. 

Does anyone have information in writing that would assist with this situation?


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