Wiki Please audit this exam

[OliviaPrice]

If the physician documents:
Physical Exam
Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.

How many points would this be and what organ systems and/or body areas would you assign this to?

 

[purplescarf23]

I would count:
supple under Musculoskeletal
no JVD, no carotid bruits under Neck
no lymphadenopathy under Lymphatic

3 total for an EPF exam

Hope that helps.

Kelsey, CPC

 

[btadlock1]

If the physician documents:
Physical Exam
Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.

How many points would this be and what organ systems and/or body areas would you assign this to?

I see these statements all of the time - I give it 3 bullets:

Supple is 'examination of neck' bullet
'No cartoid bruits' falls under a cardiovascular bullet
and 'no thyromegaly' is under neck, examination of thyroid.

The jugular vein isn't listed as a bulleted exam element, so it gets no credit, and "no lymphadenopathy" is too vague to meet the minimum requirements of the lymphatic system's bullet, which requires the examination of at least 2 lymph node areas; the neck is only one.

Hope that helps!

 

[OliviaPrice]

Thanks for responding!

I would normally give this statement credit for 3 systems/areas:
Neck - Supple, no thyromegaly
Cardiovascular - no JVD, no carotid bruits
Lymphatic - no lymphadenopathy

But I recently received an opinion that if the doctor uses the heading "neck" you should only count that as 1 body area no matter what is said.

Any opinions on this??

 

[btadlock1]

Thanks for responding!

I would normally give this statement credit for 3 systems/areas:
Neck - Supple, no thyromegaly
Cardiovascular - no JVD, no carotid bruits
Lymphatic - no lymphadenopathy

But I recently received an opinion that if the doctor uses the heading "neck" you should only count that as 1 body area no matter what is said.

Any opinions on this??

I don't agree with that - things are mislabeled in notes all of the time, and the doctor doesn't have to label anything, really - I typically only use 1997 guidelines, but if you're going by 1995, then I'd say you've got it right!

 

[OliviaPrice]

I agree!!

Thanks!