Cyndi113
True Blue
Hi there,
I need some help, please. From an auditing standpoint, if the ROS states ENT= ears normal, would you count this as 1 for ENT? Or does documentation need to say something differently?
Also the same for the MDs exam. Does the ENT exam need to state that ears normal, nares and throat and oral mucosa are normal.
I was taught that the MD should state each one is normal but my new docs are saying no. They say if why do we need to break it down if we are looking at each one and documenting ENT normal.
Please help.
Thanks,
I need some help, please. From an auditing standpoint, if the ROS states ENT= ears normal, would you count this as 1 for ENT? Or does documentation need to say something differently?
Also the same for the MDs exam. Does the ENT exam need to state that ears normal, nares and throat and oral mucosa are normal.
I was taught that the MD should state each one is normal but my new docs are saying no. They say if why do we need to break it down if we are looking at each one and documenting ENT normal.
Please help.
Thanks,