AThurman06
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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 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!!