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Pediatric Coding Alert

Reader Question:

Ask Physicians How to Count 'Supple Neck'

Published on Sun Sep 30, 2012

Question: When my pediatrician writes "Neck is supple," should I count the phrase as part of the musculoskeletal exam or the lymph system when tallying the E/M level?Alabama SubscriberAnswer: Supple means "able to bend." So you can always give the physician credit for the phrase "Neck is supple," as range of motion under the musculoskeletal section.Some pediatricians may use the phrase to refer to the lymph system. The term "Neck is supple" has also come to mean the physician checked the patient's node and found no swelling, meaning the patient doesn't have enlarged lymph nodes. Not all physicians like using the term this way. Regardless of which way your practice feels, be careful that you don't double-count the phrase. You can use the note under either the musculoskeletal system or the lymph system, but you shouldn't count it under both exams at the same time.Exception: You can consider the term [...]
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