Wiki GI versus Abdomen using 95 Guidelines

[ashleyj]

I'm confused as to what elements GI needs to have to count it as an organ system versus a body area using 95 Guidelines. We are being told that this system/area only counts as GI if states bowel sounds. If the provider doesn't document bowel sounds, we have to count it as a body area and not the organ system.

Example

General: Pleasant, NAD, sitting in a chair
HEENT: EOMI; no scleral icterus; MMM
Lungs: decreased breath sounds
CV: RRR,
GI: soft, NT/ND; no guarding or rebound
Extremities: WWP, No LE edema
Neuro: AAOx3; no asterixis
Skin: warm; no jaundice
Psych: Normal mood/affect


According to what we are being told, GI would not be counted as a system but rather a body area. Help would be greatly appreciated. Thanks

 

[Belarm3]

Bowel sounds

I have been searching for the same information. I have always only counted the abdomen (GI) as an organ system if bowel sounds were noted. If they are not, I count it as a body part. I can't seem to find anything documented to present to our physicians though.

 

[ashleyj]

GI System

I contacted my MAC regarding this matter who shared this with me:

"An examination of the GI system may include auscultation for bowel sounds, percussion of the abdomen to assess organ size (spleen/liver) and the presence or absence of ascites, an inguinal exam and a rectal exam. All of these components may not be medically necessary, so the provider performs the elements that are needed to assess the patient’s condition and physical complaint(s)."

Hope this helps! Contact your MAC to find out if they follow the same rules for determining GI versus Abdomen. I'm in Jurisdiction K