Wiki PE Bullets 1995

[Tonyj]

I usually count 2 points under exam for eyes and ears, nose, throat, mouth. My question is being that there is no mention of ears nor throat in the PE example below can I still count the points? Does there need to be a mention of ears, nose, throat and mouth to get credit or 1 mention of any of the 4? See PE statement below.

HEENT: Sclerae non-icteric. Pupils are equal, round, react to light. Mouth is without lesions

 

[OCD_coder]

To give credit for ENT organ system (ears, nose, throat), an exam documented for one of the three body areas is required to meet 95 DG guidelines.

The eyes are a separate organ system by 95 DG guidelines. You would be correct to give credit for two organ systems for that statement.

 

[MikeEnos]

There is nothing wrong with that statement, since there are findings of the eyes and the mouth. Here, I'll break down some varations and how I would score them:

-2 points (Eyes, and ENMT)
*HEENT: Sclerae non-icteric. Pupils are equal, round, react to light. Mouth is without lesions
*HEENT: Normal
*HEENT: PERRLA, TM's normal

-1 point: (Eyes)
*HEENT: Sclerae non-icteric. Pupils are equal, round, react to light.

-1 point: (ENMT)
*HEENT: Tongue midline. TM's normal. Mouth is without lesions

Notice how on the ones where I give credit for 2, either they list findings unique to each one, or else they state normal? For the ones where the findings are only unique to 1 system, only credit for 1 system is given.

My advice: Have your provider break out HEENT into Eyes, and ENMT.... it will make things MUCH easier.