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Please help me with this auditing problem. The physician documents abdomen: nontender, no bowel sounds. when using the 95 exam would you give him credit for the GI or no credit because abdomen is not part of the GI?
Please help me with this auditing problem. The physician documents abdomen: nontender, no bowel sounds. when using the 95 exam would you give him credit for the GI or no credit because abdomen is not part of the GI?
I don't care what the provider "titles" the exam bullet ... I go by what he actually documents having examined.
"Abdomen: nontender, no bowel sounds" counts as an exam of the GI system.
"Abdomen: obese" counts as a BODY AREA
Even when using the '95 guidelines, I frequently refer to the bullet points in the '97 guidelines to help me decide if the credit can be given for an organ system.