Exam for Neck Pain

maine4me

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I am auditing a chart for an new patient visit. Patient presents to the office for chronic neck pain. I am not sure if the Neuro portion of this exam is enough, or there should also be documentation under musculoskeletal.

If it is not enough, how does that affect the level of coding? To me it just does not seem that this exam is based on the presenting problem.

EXAM
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General: No acute distress.

HEENT: Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate.

Neck: Supple, no lymphadenopathy.

Lungs: Clear to auscultation bilaterally.

Heart: Regular rate and rhythm without murmurs or rubs.

Neuro: CN II-XII grossly intact without focal deficit.

Skin: warm, dry, no lesions/rashes
 
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I am not a physician

I am not a physician or qualified provider, so I never second guess the provider on whether what they have documented is "sufficient" for the chief complaint.

I just code what was documented. If that means the level of service is less that the provider thought it would be, well, it's a learning opportunity for the provider on how to document appropriately.

BTW ... if you are using 1995 guidelines you have a comprehensive exam (8 or more organ systems - consitutional, eyes, ENT, lymphatic, respiratory, cardiovascular, neuro and integumentary).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

maine4me

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Yes, I got the comprehensive exam too. But this patient tends to always document these same 8 systems, with th occasional side note about the presenting problem. Also the documented findings are most often the same, word for word. I probably am being to picky.
 
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