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Hi all,

I am relatively new to auditing, and was wondering if I could get some of your opinions on exam documentation. I want to code this office visit level as accurately as possible, but I am unsure whether certain statements made by our docs in their exams would count as a "bullet" in the general multi-system exam. In some cases, this could mean the difference between a detailed exam and a comprehensive exam. Here is what has me stumped:

-In the "Eyes" section, doctor states, "Sclera are nonicteric."
(I am not sure whether this statement would fall under"inspection of conjunctivae and lids" or "examination of pupils and irises." Another coder and myself are thinking sclera would fall under conjunctivae, but we need another opinion)

-In the "Eyes" section, doctor states, "Extraocular movements are intact."
(Would this count as a bullet? If so, would it be considered an exam of pupils and irises?)

-In the Respiratory section, doctor states "Lungs are clear with unlabored breathing."
(I know that unlabored breathing would count as a bullet for assessment of respiratory effort, but as for "clear"- would this be an auscultation of lungs??)

-Lastly, would credit be given for the statement "normal active bowel sounds"? I cannot locate a bullet for this anywhere, so I am thinking not; however, I would like a second opinion in case I am missing something.

Thanks so much for any help you can give!!
I'll give you what I know.

"Lungs are clear" one bullet for ausculation of lungs

"Normal active bowel sounds" no bullet for that.

I hope that this helps out a little anyway.
1997 guidelines

I'm assuming you are using 1997 guidelines ...

"sclera nonicteric" = inspection of conjuctivae and lids
"EOMI" = testing of cranial nerves (neuro section)

I'd encourage your physician to learn some of the bullets and tailor his documentation to meeting those bullets. "Lungs CTA" would be better than just "lungs clear."

1997 guidelines do not give you any credit for NABS. The physician must note presence of masses or tenderness, presence or absence of hernia, etc
For the 1995 guidelines, you would credit NABS as examining the GI system.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Thanks Ladies, that helps a lot :) Yes, I was referring to the 1997 guidelines, should have mentioned that in my post. It makes sense that EOMI would be in the neuro section, thanks so much for this clarification!!