AAPC - credentialing the business side of medicine

dsmith06351 · #1 04-02-2009, 01:59 PM

When the doctor completes a physical exam and documents that she checked the fontals on the head (for an infant) what system would this count as?

Thanks

Denise CPC-A

ARCPC9491 · #2 04-02-2009, 02:03 PM

The head is a body area, not an organ system.

FTessaBartels · #3 04-06-2009, 11:43 AM

The fontanelles (or fontanels) are the membraneous areas between the cranial bones in an infant (the "soft spot" your mom always told you to be careful of).

If you are using 1995 guidelines you would count this as a body area "Head/face." If you are using 1997 guidelines you would count this under musculoskeletal "notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions."

F Tessa Bartels, CPC, CEMC