Wiki exam example 1995 please check ED doctor's respond

[kviolet]

Below is a copy of Dr X pt’s exam:
I found 7 organ systems.
am I correct ?

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 – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· 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)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)

Belowis a respond from the ED doctor :

Thanks - but this really can’t be accurate- this is an interpretation/understanding problem:
Head and Neck should be considered an organ system just the same as “GEN: WDWN NAD No Pallor Moist Mucosa”

HEAD: includes organ systems neuro and musculoskeletal (bones): so NCAT (Normocephalic, Atraumatic)- means that the skull bones were intact, head size was normal ( for example no microcephaly or macrocephaly which might indicate a neurological condition)

Neck- includes organ systems such as NEURO and LYMPHATIC: so that
“Neck: No Meningismus No Adenopathy”- MUST be interpreted- with that in mind- “no meningismus” means that there were no neurological signs of infection and “no adenopathy” means that there were no local signs of lymphatic infection of the throat, ears, etc).

Please clarify again why things like Head and Neck should be excluded.
Also for GI- when the doctor’s write “soft, non-tender”- it is UNDERSTOOD that refers to abdomen. It should be entirely sufficient to write abdomen-soft, non-tender ( for getting credit for 1 body part in 1 organ system).
Unless you are saying that you need more than 1 element per organ system.

thanks



How should I reply ? Thanks for any help!!!

 

[jimbo1231]

Systems vs. Areas

This issue is a tough sell to some physicians. But the fact is if the physician wanted you to identify systems he should have properly labeled the appropriate systems such as Neuro on the chart. If he is using an EMR, this shouldn't be difficult. Maybe providing him with a copy of your coding/audit tool that separates systems from areas might help. It might also help to explain to him that upon third party audit, the auditor will do the same thing you did. Of course his response will be that he'd challenge the Medicare auditor and win. Hard to argue with ego sometimes!

Having said all this I will sometimes give a doc a break. For example if they label abdomen and clearly they are doing a GI exam I will go with that. I'm probably being to nice though. There is no reason they can't label areas properly particularly with an EMR (and often a scribe).

Jim