Wiki E and M exam question

[becca12]

Hello all,

I have a question if you have a doctor that just puts down head normal would you count that as one ENT or would you not even count it.

Thanks,
Rebecca RHIT CPC

 

[bertll]

I would count that as a body area, head, for the exam.

 

[hewitt]

Remember, the exam is a review of pertinent positives and negatives of an Organ System or Body Area. The head is not classified as an organ system. When you look at the bullet points for ENT under the 1997 Coding Guidelines, there are very specific observations that must be documented to qualify the head as a bullet point under ENT. I would say if he just mentions the head without enumerating positives and negatives, you could count it as a Body Area.

 

[becca12]

Thanks so much if they would teach e and m coding in medical school that would be very good thing!!!!