britbrit852003
Guru
The coders in my office are having a disagreement on what give "credit" for on the exam portion in the E/M. We use the 1995 guidelines.
Here the two examples:
Example #1
One person says we cannot give "credit" for the "mouth" as part of the ENT because the provider did not examen the whole ENT system.
General:
well developed, well nourished, in no acute distress
Head:
normocephalic and atraumatic
Eyes:
conjunctiva and sclera clea
Mouth:
no deformity or lesions, normal teeth and gums,tongue normal, salivary glands normal
Lungs:
clear bilaterally to P P & A with good breath sounds. No wheezes with forced expiration. Excellent air movement.
Example #2
Would you give "credit" for the "endocrine system" for the statement of no thyromegaly under neck? Would you give "credit" for musculoskeletal for full range of motion under extremities? One coder says those are body areas and cannot be counted toward the exam but I feel that they go more into organ systems when you read it that you can count it.
General:
well developed, well nourished, in no acute distress.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
Pulses:
pulses normal in all 4 extremities.
Extremities:
no clubbing, cyanosis, edema, or deformity noted with normal full range of motion of all joints.
Neurologic:
no focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.
Here the two examples:
Example #1
One person says we cannot give "credit" for the "mouth" as part of the ENT because the provider did not examen the whole ENT system.
General:
well developed, well nourished, in no acute distress
Head:
normocephalic and atraumatic
Eyes:
conjunctiva and sclera clea
Mouth:
no deformity or lesions, normal teeth and gums,tongue normal, salivary glands normal
Lungs:
clear bilaterally to P P & A with good breath sounds. No wheezes with forced expiration. Excellent air movement.
Example #2
Would you give "credit" for the "endocrine system" for the statement of no thyromegaly under neck? Would you give "credit" for musculoskeletal for full range of motion under extremities? One coder says those are body areas and cannot be counted toward the exam but I feel that they go more into organ systems when you read it that you can count it.
General:
well developed, well nourished, in no acute distress.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
Pulses:
pulses normal in all 4 extremities.
Extremities:
no clubbing, cyanosis, edema, or deformity noted with normal full range of motion of all joints.
Neurologic:
no focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.