Wiki 1997 Bullets

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btadlock1

btadlock1

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Okay - I have a few phrases that I keep seeing in charts, and I'm not particularly comfortable giving credit for them under the 1997 Multisystem guidelines...I'd like to get some thoughts on these - (Sorry of some are redundant from other posts - I just want to get them all on the same page...)
Would you give credit, under which bullet, and why?

Eye: Extraocular movements are intact
HENT: Normocephalic
Neck: Non-tender, no lymphadenopathy
Psych: Cooperative

Thanks!
 
Here's my opinion

Eye: Extraocular movements are intact - NO bullet under Eyes. This is a measure of cranial nerves, so would fall under Neuro in 1995 guidelines. 1997 just has "test cranial nerves with notation of any deficits" ... I might give credit for 1 bullet here, but usually we see documentation of All the cranial nerves II-XII.

HENT: Normocephalic - NO bullets under 1997

Neck: Non-tender, no lymphadenopathy - 1 bullet for "examination of neck (e.g. masses, overall apperance, symmetry, tracheal position, crepitus)

Psych: Cooperative - no bullet, though I might be persuaded to count this as Constitutional for general appearance.


If they are going to use 1997 guidelines exclusively, your providers REALLY need to look at the audit sheet for the 1997 guidelines and learn to document to specifically meet the bullet points listed there.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Tessa,

"HENT: Normocephalic - NO bullets under 1997"

Out of curosity, why wouldn't you count this statement under M/S--->head/neck

Head/Neck-Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

Normocephalic=refers to an individual whose head and major organs associated with the head are in a normal condition without significant abnormalities.
 
RebeccaWoodward* said:
Tessa,

"HENT: Normocephalic - NO bullets under 1997"

Out of curosity, why wouldn't you count this statement under M/S--->head/neck

Head/Neck-Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

Normocephalic=refers to an individual whose head and major organs associated with the head are in a normal condition without significant abnormalities.
Click to expand...

I never considered that...but would it be safe to assume that he's referring to the joints, bones, and muscles, specifically, or would he need to elaborate?

I had been leaning towards counting it as 'External inspection of ears and nose', because if his HENT is without significant abnormalities, it would be logical to say that their ears and nose were anatomically 'normal', too. I'm just not sure if it's detailed enough to meet the requirements of either bullet, though. If I could count it under M/S, could I also count it under ENT, under the same premise?:confused:

And let me ask you guys about this one...(Forgive me for thinking out loud, here...:eek:)
Would you give credit under 'ascultation of heart', for the statement "Normal rate, regular rhythm" (by itself)? I'm okay with giving credit when they also say "no murmur", but it's not always there. My problem with the shorter statement is: is that something that you could determine without actually listening to their heart; or could they make that assessment by reviewing the vital sign info (BP, pulse rate and regularity)?
The word "rhythm" is what's really tripping me up - if I understand the word 'rhythm' correctly, it's the consistency of the beat over a given time frame. The easiest way to detect it would be hearing it, but it seems to me, like you also feel the rhythm by feeling their pulse, which is not a bullet. So should he have to actually say something to indicate that he listened to it (like, 'no murmur'), or am I asking for too much?

I know I'm being really anal about these guidelines, but I'm trying to audit these charts the way that an RAC or OIG auditor might, and I've got so much to go over with these providers about their documentation already, that I don't want to critique them on anything that's not necessary. But I won't be doing anybody any favors by letting them think that some of these things are acceptable, either, if they're not. I just want to make sure I'm not out of line. :eek:
 
I don't feel comfortable crediting Normocephalic towards 'External inspection of ears and nose'. There isn't an actual referene to ears and nose; but that's just me. When referring to normocephalic, the provider is indicating that the head is normal...absent of misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, etc. I can tell you that I have had outside consultants/auditors audit my performance and they allowed Normocephalic towards M/S, Head/Neck.

As for "Normal rate, regular rhythm", I would credit "auscultation of heart''. Typically, the provider places a stethoscope on the chest and listens to the rhythm and rate. He/she is listening for abnormal heart sounds.
 
Conservative approach

As I've indicated before, I tend to be conservative in my auditing.

In Pediatrics I frequently see:
Head - normocephalic, atraumatic, anterior fontanelle soft and flat

Now, I would give credit under MS for the above - because it clearly shows an examination of the head. But just saying "normocephalic" doesn't seem to satisfy me as far as letting me know that the head was examined vs the provider just looked at the patient.

Hope that made sense.

As I said ... I'm conservative. And if a practice has stated they are adopting 1997 rules exclusively, then they need to document to 1997 standard.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
As I've indicated before, I tend to be conservative in my auditing.

In Pediatrics I frequently see:
Head - normocephalic, atraumatic, anterior fontanelle soft and flat

Now, I would give credit under MS for the above - because it clearly shows an examination of the head. But just saying "normocephalic" doesn't seem to satisfy me as far as letting me know that the head was examined vs the provider just looked at the patient.

Hope that made sense.

As I said ... I'm conservative. And if a practice has stated they are adopting 1997 rules exclusively, then they need to document to 1997 standard.

F Tessa Bartels, CPC, CEMC
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I'd like to think I'm conservative too and I can assure you that our providers document according to the documantation guidelines. "Vague" is certainly debatable; as is E/M coding. It is a subjective area and there are many, many styles of documenation. One style doesn't hold truth over another.
 
RebeccaWoodward* said:
I'd like to think I'm conservative too and I can assure you that our providers document according to the documantation guidelines. "Vague" is certainly debatable; as is E/M coding. It is a subjective area and there are many, many styles of documenation. One style doesn't hold truth over another.
Click to expand...

Thank you both SO much! The differences of opinion are something I expected (and hoped) to see, which is why I came here instead of relying on articles from web searches - everyone seems to have a different idea of what's 'good enough' and what's not - I trust your experience and opinions, though!:D (And to be honest, seeing that there are even disagreements between people as well-versed in the subject as y'all are, really makes me feel better about struggling with it myself! :eek:)

I believe that I'm going to take Tessa's approach on the charts I'm currently working on, for the sake of educating the providers - the bottom line is: they need to be more specific, so there's no room for debate. If they happen to get reviewed by the strictest auditor on the planet, I want to be sure that their bases are covered. (Hope for the best, but prepare for the worst!:p)

That's not to say that I disagree with you (Rebecca) at all, though; you've given me some valuable insight to use, should I ever need to defend the viability of the current documentation to anyone. I will go ahead and allow credit for 'normal rate, regular rhythm', and ask the doctors to make it more clear that they determined that by ascultation, and not by any other method. I appreciate it!
 
btadlock1 said:
Thank you both SO much! The differences of opinion are something I expected (and hoped) to see, which is why I came here instead of relying on articles from web searches - everyone seems to have a different idea of what's 'good enough' and what's not - I trust your experience and opinions, though!:D (And to be honest, seeing that there are even disagreements between people as well-versed in the subject as y'all are, really makes me feel better about struggling with it myself! :eek:)

I believe that I'm going to take Tessa's approach on the charts I'm currently working on, for the sake of educating the providers - the bottom line is: they need to be more specific, so there's no room for debate. If they happen to get reviewed by the strictest auditor on the planet, I want to be sure that their bases are covered. (Hope for the best, but prepare for the worst!:p)

That's not to say that I disagree with you (Rebecca) at all, though; you've given me some valuable insight to use, should I ever need to defend the viability of the current documentation to anyone. I will go ahead and allow credit for 'normal rate, regular rhythm', and ask the doctors to make it more clear that they determined that by ascultation, and not by any other method. I appreciate it!
Click to expand...


I can certainly respect that. I think you're doing a great job! The statement below is taken directly from the 97 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).

The providers statement may not jive with some, but the guidelines are supportive.

HENT-Normocephalic=refers to an individual whose head and major organs associated with the head are in a normal condition without significant abnormalities.
 
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Mary Shults LPN-CPC

Just wondering why the documentation "Cooperative" would not satisify a psych bullet as it describes the patients ability to understand and respond accordingly????? It seems to describe something about the patients psychological capabilities. Do you think it would stand in audit?















:)QUOTE=FTessaBartels;152010]Eye: Extraocular movements are intact - NO bullet under Eyes. This is a measure of cranial nerves, so would fall under Neuro in 1995 guidelines. 1997 just has "test cranial nerves with notation of any deficits" ... I might give credit for 1 bullet here, but usually we see documentation of All the cranial nerves II-XII.

HENT: Normocephalic - NO bullets under 1997

Neck: Non-tender, no lymphadenopathy - 1 bullet for "examination of neck (e.g. masses, overall apperance, symmetry, tracheal position, crepitus)

Psych: Cooperative - no bullet, though I might be persuaded to count this as Constitutional for general appearance.


If they are going to use 1997 guidelines exclusively, your providers REALLY need to look at the audit sheet for the 1997 guidelines and learn to document to specifically meet the bullet points listed there.

Hope that helps.

F Tessa Bartels, CPC, CEMC[/QUOTE]
 
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