Wiki Exam Question

[britbrit852003]

The coders in my office are having a disagreement on what give "credit" for on the exam portion in the E/M. We use the 1995 guidelines.
Here the two examples:

Example #1
One person says we cannot give "credit" for the "mouth" as part of the ENT because the provider did not examen the whole ENT system.

General:
well developed, well nourished, in no acute distress
Head:
normocephalic and atraumatic
Eyes:
conjunctiva and sclera clea
Mouth:
no deformity or lesions, normal teeth and gums,tongue normal, salivary glands normal
Lungs:
clear bilaterally to P P & A with good breath sounds. No wheezes with forced expiration. Excellent air movement.


Example #2
Would you give "credit" for the "endocrine system" for the statement of no thyromegaly under neck? Would you give "credit" for musculoskeletal for full range of motion under extremities? One coder says those are body areas and cannot be counted toward the exam but I feel that they go more into organ systems when you read it that you can count it.

General:
well developed, well nourished, in no acute distress.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
Pulses:
pulses normal in all 4 extremities.
Extremities:
no clubbing, cyanosis, edema, or deformity noted with normal full range of motion of all joints.
Neurologic:
no focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.

 

[MikeEnos]

The coders in my office are having a disagreement on what give "credit" for on the exam portion in the E/M. We use the 1995 guidelines.
Here the two examples:

Example #1
One person says we cannot give "credit" for the "mouth" as part of the ENT because the provider did not examen the whole ENT system.

General:
well developed, well nourished, in no acute distress
Head:
normocephalic and atraumatic
Eyes:
conjunctiva and sclera clea
Mouth:
no deformity or lesions, normal teeth and gums,tongue normal, salivary glands normal
Lungs:
clear bilaterally to P P & A with good breath sounds. No wheezes with forced expiration. Excellent air movement.


Example #2
Would you give "credit" for the "endocrine system" for the statement of no thyromegaly under neck? Would you give "credit" for musculoskeletal for full range of motion under extremities? One coder says those are body areas and cannot be counted toward the exam but I feel that they go more into organ systems when you read it that you can count it.

General:
well developed, well nourished, in no acute distress.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
Pulses:
pulses normal in all 4 extremities.
Extremities:
no clubbing, cyanosis, edema, or deformity noted with normal full range of motion of all joints.
Neurologic:
no focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.

There's a lot of questions in here, so I'll try to answer each one.

One person says we cannot give "credit" for the "mouth" as part of the ENT because the provider did not examen the whole ENT system.

Yes, you would get credit for ENMT with a relevant finding of the mouth. You do not need to also document a finding of the ears, nose and throat to get credit for it. I would advise that if you have docs who document HEENT: PERRLA then I would only give credit for eyes, since that's the only finding listed.

Would you give "credit" for the "endocrine system" for the statement of no thyromegaly under neck?

Well, endocrine system is not part of the physical exam. It is certainly an examination of the neck though. I would give credit for Hem/Lymph/Immune for a statement of "No lymphadenopathy." The neck can actually give a lot of information about different organ systems on exam. Pay attention to the findings... Range of Motion of neck is musculoskeletal, swollen lymph glands are a hem/lymph finding, whereas rigidity is a finding about meningitis or possibly strep throat. Jugular Vein Distension (JVD) would be a cardiovascular finding. Perhaps there is an assessment of the skin (lesions, warts, skin tags, etc.) All of these may be observed in one examination of the neck.

Would you give "credit" for musculoskeletal for full range of motion under extremities? One coder says those are body areas and cannot be counted toward the exam but I feel that they go more into organ systems when you read it that you can count it.

Yes, I would give credit for a musculoskeletal finding for range of motion. In addition, you have examination of digital clubbing, which is a musculoskeletal finding. You can absolutely count body areas towards the exam, although a comprehensive exam must be 8 organ systems (body areas don't count) so it's always a good idea to give credit according to the organ system the finding is geared toward, even if it is labeled as a body area.