Wiki Eent

[paintbrush]

When a physician states EENT negative on his exam should he be given credit for eyes and ears nose and throat. I could use some documentation to support this or documentation to support that they would only be given credit for one of the systems.

 

[rthames052006]

When a physician states EENT negative on his exam should he be given credit for eyes and ears nose and throat. I could use some documentation to support this or documentation to support that they would only be given credit for one of the systems.

I have always given credit for 2 systems when the physician states either HEENT or EENT negataive.

I would think as long as that system is not part of the "CC" that is fine to state negative.

 

[FTessaBartels]

ROS or exam?

Are you talking about the ROS or the exam?

I'd count two systems on ROS.

For the exam:
If using 1997 guidelines "EENT negative" gives you NO bullet points at all. It's not much more effort to dictate: "PERRLA. TMs clear" That would get you 2 bullet points.

If using 1995 guidelines I might give credit for 2 with "EENT negative" ... but I'd educate the physician about audit-proof documentation.

F Tessa Bartels, CPC, CEMC