Kcronin1122
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Hello,
I am having a hard time with one of my doctors with billing for a complete comprehensive exam. I am only counting 7 Organ systems in their exam. Can anyone else look at the exam below and tell me how many organ systems they are finding?
General appearance: alert, cooperative, no distress
Head: Normocephalic, without obvious abnormality
Eyes: negative findings: No redness or drainage
Neck: supple, symmetrical, trachea midline, no carotid bruit and no JVD
Back: no skin lesions, erythema, or scars, no tenderness to percussion or palpation
Lungs: clear to auscultation bilaterally, no crackles, no wheezes, chest expansion normal
Chest wall: left sided chest wall tenderness at times, not consistent
Heart: RRR, normal S1 and S2, no murmur, no S3 or S4, no rub
Abdomen: soft, present bowel sounds, tender to palpation at left upper quadrant which patient states is chronic
Extremities: extremities normal, atraumatic, no cyanosis or edema
Pulses: 2+ and symmetric
Skin: Skin color, texture, turgor normal. No rashes or lesions
Neurologic: Alert and oriented X 3
Thanks
I am having a hard time with one of my doctors with billing for a complete comprehensive exam. I am only counting 7 Organ systems in their exam. Can anyone else look at the exam below and tell me how many organ systems they are finding?
General appearance: alert, cooperative, no distress
Head: Normocephalic, without obvious abnormality
Eyes: negative findings: No redness or drainage
Neck: supple, symmetrical, trachea midline, no carotid bruit and no JVD
Back: no skin lesions, erythema, or scars, no tenderness to percussion or palpation
Lungs: clear to auscultation bilaterally, no crackles, no wheezes, chest expansion normal
Chest wall: left sided chest wall tenderness at times, not consistent
Heart: RRR, normal S1 and S2, no murmur, no S3 or S4, no rub
Abdomen: soft, present bowel sounds, tender to palpation at left upper quadrant which patient states is chronic
Extremities: extremities normal, atraumatic, no cyanosis or edema
Pulses: 2+ and symmetric
Skin: Skin color, texture, turgor normal. No rashes or lesions
Neurologic: Alert and oriented X 3
Thanks
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