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Wiki EPF versus Detailed Exam

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cheriefieri

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If a medical record indicates 'Lymph Nodes Exam: Normal' in addition to ENT exam, would this be counted as a separate Body Area (Neck) in addition to Head or would it be recorded as a separate Organ System under Hematolgical/Lymphatic? Depending on how one views may be difference between an EPF or Detailed Exam in several of the visits I am coding.
 
Organ system

I'm assuming you are using 1995 guidelines.

I would count is a organ system Heme/lymph ... the statement 'lymph nodes normal" doesn't tell me WHERE on the body the nodes examined are located. So our only option is to count it as an organ system.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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