Wiki Physical Exam Bullets

[bdye]

I am auditing a new physician with a Cardiology practice. He is dictating for the Neurological system "Nonfocal". To me, this means nothing - am I wrong?

 

[OCD_coder]

Nonfocal means "normal" exam to a clinician. No focused injury or problem.

 

[bdye]

Okay - But he is wanting credit for all of the Neuro bullets (Cranial Nerves, Deep Tendon Reflexes, Sensation). I believe that these should be documented separately - am I wrong?