1997 Exam

janice.moore

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I need some help from those using the 1997 guidelines. How specific do you expect your providers to be? Is "sclera" acceptable in place of conjunctiva? Is "organomegaly" acceptable in place of hepatomegaly or splenomegaly? "Peripheral pulses" acceptable in place of "pedal pulses", etc. I feel the bullet is what it is unless it has an "e.g." following it. Others don't agree. Any opinions? Thanks!!
 

Pam Brooks

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exam documentation

I think that all of the alternative documentation you mentioned in your thread would be appropriate bullet items. The intent is not to have a "cookie cutter" chart, but to document the areas/organ systems and the various items within those systems in a way that identifies an appropriate exam. It's up to the coder to understand the many terms that would constitute the exam bullets, so that she/he is not depending on the provider to document word-for-word chart notes just to satisfy the bullet requirements. Use your Taber's or other medical dictionary if you are unsure of the terminology. Pam Brooks, CPC
 
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