sullivak
Guru
Hi,
I have this exam and am trying to see if I'm on the right track in coding for 97 guidelines, multispecialty. Please let me know your take! My thoughts are in brackets.
Appearance: Alert. Oriented X3. No acute distress. [Constitutional: gen appearance; Psych orientation] 2 points
Vital Signs: Normal. (BP: 10 7 / 69 sitting. HR: 85. RR: 20. Temp: 98.1 oral. O2 saturation: room air:100 percent.). [sitting BP; Pulse; resp rate; temp] - 1 pt
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. [eyes - pupils, irises; no credit for eyes normal inspection not specific enough] 1 point
ENT: Ears normal. Nose normal. Pharynx normal. [No credit for ears and nose or for oropharynx - not specific enough]
Neck: Normal inspection. Neck supple. [Neck-masses, appearance] 1 point
CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal. [Cardiovascular-auscultation; no credit for pulses because not specific enough] 1 point
Respiratory: No respiratory distress. Breath sounds normal. Chest nontender. [Respiratory effort; auscultation of lungs; palp of chest] 3 points
Abdomen: Soft. Moderate tenderness diffusely. No guarding or rebound tenderness. Bowel sounds normal. No organomegaly. No mass. [Abdomen, masses/tenderness; liver, spleen] 2 points
Back: Normal inspection. [musculoskeletal - inspect,palp spine ribs or pelvis] 1 point
GU: Normal external exam. Speculum exam normal. No vaginal bleeding. Mild uterine tenderness. No right adnexal tenderness. No left adnexal tenderness. No cervical motion tenderness. Uterus not enlarged. [external genitalia; Uterus; Adnexa; Cervix] 4 points
Skin: Skin warm. Normal skin color. No rash. [palp skin; inspect skin] 2 points
Extremities: Extremities exhibit normal ROM. No lower extremity edema. [Cardiovascular-extremities for edema; no credit for extremities ROM because not specific enough] 1 point
Overall - 19 bullets?
What's your take? Am I being too strict with this documentation? This note includes a number of the issues that my coworkers and I argue about.
Thanks! Kim
I have this exam and am trying to see if I'm on the right track in coding for 97 guidelines, multispecialty. Please let me know your take! My thoughts are in brackets.
Appearance: Alert. Oriented X3. No acute distress. [Constitutional: gen appearance; Psych orientation] 2 points
Vital Signs: Normal. (BP: 10 7 / 69 sitting. HR: 85. RR: 20. Temp: 98.1 oral. O2 saturation: room air:100 percent.). [sitting BP; Pulse; resp rate; temp] - 1 pt
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. [eyes - pupils, irises; no credit for eyes normal inspection not specific enough] 1 point
ENT: Ears normal. Nose normal. Pharynx normal. [No credit for ears and nose or for oropharynx - not specific enough]
Neck: Normal inspection. Neck supple. [Neck-masses, appearance] 1 point
CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal. [Cardiovascular-auscultation; no credit for pulses because not specific enough] 1 point
Respiratory: No respiratory distress. Breath sounds normal. Chest nontender. [Respiratory effort; auscultation of lungs; palp of chest] 3 points
Abdomen: Soft. Moderate tenderness diffusely. No guarding or rebound tenderness. Bowel sounds normal. No organomegaly. No mass. [Abdomen, masses/tenderness; liver, spleen] 2 points
Back: Normal inspection. [musculoskeletal - inspect,palp spine ribs or pelvis] 1 point
GU: Normal external exam. Speculum exam normal. No vaginal bleeding. Mild uterine tenderness. No right adnexal tenderness. No left adnexal tenderness. No cervical motion tenderness. Uterus not enlarged. [external genitalia; Uterus; Adnexa; Cervix] 4 points
Skin: Skin warm. Normal skin color. No rash. [palp skin; inspect skin] 2 points
Extremities: Extremities exhibit normal ROM. No lower extremity edema. [Cardiovascular-extremities for edema; no credit for extremities ROM because not specific enough] 1 point
Overall - 19 bullets?
What's your take? Am I being too strict with this documentation? This note includes a number of the issues that my coworkers and I argue about.
Thanks! Kim