SD_CodingCAC
New
I'm trying to differentiate between what should count as a urethra exam and a urethral meatus exam in 1997 guidelines. It seems like the urethral meatus is more likely to be examined since it's external, but does "meatus" need to be documented to count this? And what documentation would constitute a true urethra exam?
97 Bullet Points:
1. The patient is able to express a purulent urethral discharge. This was cultured.
2. Urethra does not look irritated.
3. No urethral discharge, phimosis, herpes-like lesions or paraphimosis.
Any input is greatly appreciated!
97 Bullet Points:
- Examination of urethra (eg, masses, tenderness, scarring)
- Urethral meatus (eg, size, location, lesions, discharge)
1. The patient is able to express a purulent urethral discharge. This was cultured.
2. Urethra does not look irritated.
3. No urethral discharge, phimosis, herpes-like lesions or paraphimosis.
Any input is greatly appreciated!