ED Coding and Reimbursement Alert

Reader Questions:

Count the Elements for Physical Exam

Published on Thu Feb 10, 2022

Question: Sometimes I’m coding a chart and can’t decide how to classify the documentation of a physical exam element. Most are pretty straightforward, like “lungs clear” for respiratory or “normal bowel sounds” for abdomen, but how do you count vague statements like “neck supple” or “abdomen soft”?

Here is a chart of a physical exam I recently coded. I only found 7 organ systems and can’t count mix in body areas as well towards the required 8 systems for a comprehensive exam. Do you agree with my 7 systems?

Physical Exam:

Gen: Alert WDWN NAD No Pallor Moist Mucosa (1) Head: NCAT (body area) Eyes: Conj/lids within normal limits (2) Neck: No Meningismus. No Adenopathy (body area) Lungs: CTA No wheezes/rhonchi/rales. No retractions (3) CV: Normal Perfusion. Peripheral Pulses. Normal RRR. No murmurs/gallops/rubs (4) GI: Soft Non-tender (I feel this describes more of a body area, the abdomen, rather than an organ system.) Skin: Right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. No tenderness. (5) Neuro: Normal gait (6) neuro no fluctuance. No induration. Extremities: FROM Capillary refill within normal limits. Peripheral pulses within normal limits (7)

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Answer: The seven listed systems are accurate, but there are a few more you should have highlighted as well. See below for every element that is countable in this exam documentation:

Physical Exam:

Gen: Alert, well developed and well nourished, No acute distress, No Pallor, [CONST] (1) Moist Mucosa [ENT] (2)

Head: NCAT (body area)

Eyes: Conj/lids within normal limits [EYES] (3)

Neck: No Meningismus [NEURO] (4) No Adenopathy [LYMPH] (5) Lungs: Clear to auscultation, No wheezes/rhonchi/rales, No retractions [RESP] (6) CV: Normal Perfusion, Peripheral Pulses Normal, RRR, No murmurs/gallops/rubs [CARDIO] (7) GI: Soft Non-tender This could be better but still supports counting as GI documentation. See note below for more explanation [GI] (8)

Skin: Right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. No tenderness. [INTEG] (9)

Neuro: Normal gait, no fluctuance. No induration. [NEURO again]

Extremities: FROM Capillary refill within normal limits. Peripheral pulses within normal limits [Cardio again]

Regarding the notation of “Soft non-tender,” for the physician to document this assessment finding, they must have palpated the abdomen. This done in two steps:

First is light palpation. This may reveal a variety of symptoms, muscle resistance/rigidity, masses, mobility, pulsatility, or tenderness. Depending on the cause of these findings, they could be applied to different organ systems.

The second step is deep palpation. The physician is feeling for the patient’s organs. Organs normally palpable are the liver edge, right kidney lower pole, cecum (ascending colon), sigmoid colon, full bladder, or gravid uterus. Having evaluated those organs, positive findings could be GI, GU, or cardio. Conversely, the lack of finding would typically also be able to be applied to at least some of these systems.

You can typically count “soft, non-tender” as a GI exam. As for the always confusing “Neck: Supple,” the use of the word “supple” to describe the neck refers to the fact that it can be easily bent. Stiff necks are a common physical sign in meningitis, so counting this as neuro makes sense, but you usually get a separate neuro exam, so it may not always boost your organ system count. With these nine organ systems identified, you qualify for a comprehensive physical exam.