Wiki E/M Audit

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cbooker

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We have a physician who states that he does not have to separate the eyes from the ENT exam. On the note he usually states HEENT is unremarkable. According to guidelines that I have found this would only qualify to one point when performing an audit. Does anyone have any documentation stating that the eyes need to be seperate when documenting exam.
 
I can tell you that some carriers do not allow HEENT normal or unremarkable. As a matter of fact, Deborah Griders book "Medical Record Auditor" (supported by the AMA) states..."Also, many carriers will not allow credit for the statement "HEENT, normal". The question always arises, WHAT system in HEENT did the MD examine? HEENT includes includes the head, eyes, ears, nose and throat."
 
I prefer to see something like this....

HEENT: PERRLA, EOMI; EACs and TMs nl; oropharynx benign. (In a perfect world, right?)

I do think that that the 95 DG's are a little more lienent with HEENT normal. I certainly would not allow the statement scoring with 97 DG's. However, in all fairness to your provider, I would contact your carrier(s) for their view. If you can obtain a written statement from them, all the better!
 
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