Wiki help needed with auditing a pediatrician

[suzannereed]

I am new to auditing E/M coding for a pediatrician, and I need help please!

When my pediatrian documents under physical examination "no meningeal signs" do I give him credit under neurologic? But for what element of examination, test cranial nerves with notation of any deficits, or examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski), or examination of sensation (e.g. by touch, pin, vibration, proprioception). I have searched on the Internet, but can't find a clear answer. Can anyone help please?

 

[C4VETTE]

Ped coding

Being new I think you are over thinking it. Just count it for 'one'. E/M wise you are counting. You are not having to decifer it. I code Ped's too.

 

[carolbuchmann]

1995 Neuro
1997-- give him the bullets and have him tell you--- then perhaps offer him a template that may help to differentiate his exam.

 

[suzannereed]

Thank you both for your replies. I sure do appreciate your help.

 

[FTessaBartels]

1995 guidelines

In general I find the 1995 guidelines much better for pediatrics. I mean you can't do a pelvic on a 9-month old (nor typically a digital rectal exam, or breast exam, or ...)

Hope that helps.

F Tessa Bartels, CPC, CEMC