Internal Medicine Coding Alert
Coding ROS When Documentation Indicates 'HEENT Normal'
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Question: Using the 1997 General Multi-System Examination Guidelines, how do you classify the statement: HEENT is normal? Do you count it as an entire review of all nine bullets within the eyes, ears, nose and throat sections?
Anonymous IL Subscriber
Answer: No, says Hill. You can count only one element in each of the included systems. ENT is one system, and the eyes count as a second system, according to the guidelines. There is not a separate system for the head.
You would basically get credit for two bulleted items, she says. A check in eyes and a check in ENT.
The proposed new evaluation and management (E/M) guidelines state the same requirement more clearly, Hill adds. But, these are still just proposed guidelines and not final.
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