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Pediatric Coding Alert

Reader Question:

Stick Your Neck Out for Correct ROS Choice

Published on Mon Jul 26, 2004

Question: Our doctors use the phrase "neck is supple" all the time in their documentation. We are virtually ignoring it because we don't really know which part of the physical exam it should accompany. Can I count it anywhere without elaboration from the doctor? Kansas Subscriber Answer: You are certainly not the only coder struggling here: This phrasing is a common problem, because "neck" is technically a body area rather than an organ system. In the end, the physician should locate the system. Some coders consider "neck is supple" as part of the musculoskeletal exam, while others consider it to be part of the lymph or neurological system. You may also want to consider the reason for the physician's exam.
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