maine4me
Guru
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
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
*****
*****
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