Wiki Do these bullets count?

[margieclark]

While reading E&M notes at our clinic, my co-worker and I often debate if any of these items count as a bullet under the PE portion of the visit. Sometimes our doctors are close to being able to code a higher level and we are on the fence about whether or not these things count.

Head: Normocephalic
Sinuses: No pain with palpatation
Cardio: Normal S1 & S2

Also, If the doc does an internal and external exam of the ears, is this one bullet or two.

Opinions are appreciated. Thanks!!

 

[dkluvssm]

For Head: Normocephalic and Sinuses: No pain w/ palpation - I give credit for either or both statements (97 guidelines) Musculoskeletal - Head/Neck - Inpection/Palpation (1 bullet)
Cardio: Nornal S1 & S2 - I give credit under Cardiovascular - Auscultation.

For internal and external inspection of ears - what verbiage is the provider using? When inspecting the internal ears I look for verbiage that includes the TMs and/or auditory canals. The External inspection is one that has always been a tough one for me to understand the reasoning for it. One provider told me that when does an external inspection of the ears he is also looking at the nose and the alignment of them. He explained that the ear/nose alignment may indicate a condition. But per 97 guidelines the external inspection of ears/nose would possibly include some mention of scars lesions or masses. (which in my opinion would be credited under the SKIN exam).