Wiki Query about Physical Examination

[jibinzachariah]

Dear Team,

A note from the CMS E/M coding guidelines;

DG: A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)


Does this mean “normal” is sufficient based on the description of comprehensive examination; see the below example from our documentation

Cardiovascular: Normal
Ears, Nose, Mouth and Throat: Normal
Eyes: Normal
Genitourinary (Female): Normal
Hematologic/Lymphatic/Immunologic: No allergy
Musculoskeletal: Normal
Neurological: Normal
Psychiatric: Normal
Respiratory: Normal
Skin: Normal

 

[smoore123]

What was the presenting problem (s)?

 

[jibinzachariah]

presenting problems are fever and cough..

Thanks...

 

[smoore123]

Technically you can give them credit based on the guidance although I definitely would make this a talking point with the provider. Just curious what level of service are they trying to bill?