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Wiki Exam Questions

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klamm

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Are the description of the doctor's finding from the exam clear enough that they can be counted? I was dinged on an audit for counting these towards the exam, the auditor said they were not descriptive enough. Would like some other opinions.

HENT: Normocephalic
Musculoskeletal: Normal Range of Motion, Normal Strength
Integumentary: Intact

Thanks
KLamm
 
klamm said:
Are the description of the doctor's finding from the exam clear enough that they can be counted? I was dinged on an audit for counting these towards the exam, the auditor said they were not descriptive enough. Would like some other opinions.

HENT: Normocephalic
Musculoskeletal: Normal Range of Motion, Normal Strength
Integumentary: Intact

Thanks
KLamm
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I disagree with your auditors findings. It's only necessary to give more information if commenting on abnormal findings. Negative or normal findings are just that normal. see page 32 of Med Learn link attached

http://www.cms.gov/Outreach-and-Edu.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf

DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).
 
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