Normocephalic is musculoskeletal in my opinion.
The definition you list seems way to broad. Lets think about how many organ systems are present in the head area: skin, eyes, ent, neuro, cv, resp, lymph, and m/s. You could probably make the argument for more even. So what determines "major"?
Are your providers trying to say they are lumping multiple systems in that one statement? I would ask them what they mean when they say that. If they feel they should be getting credit for multiple systems I would educate them to document more specifically and break it down into the different systems.
95 exam is not well defined. You are at the mercy of the auditor. All auditors have the potential to see things differently. The more clear and concise your documentation is the better it will fare in an audit situation. Documentation should not be about what you can get away with. It should paint a clear picture of the patients status and the work that the provider is doing. Then the coding should accurately represent what is shown in the documentation.
Laura, CPC, CPMA, CEMC