You Be the Coder:
Is That Physical Exam Element an Organ System or a Body Area?
Published on Mon May 23, 2016
Question: Sometimes I’m coding a chart and can’t decide how to classify the documentation of a physical exam element. Most are pretty straight forward, 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 [...]