Exam

[Jenna000]

How does everyone feel about the use of normal in the exam, for example:

HEENT normal

or do drs need to be more explicit, as in:
class one airway, poor dentation?

thanks!
Jenna

 

[Tonyj]

How does everyone feel about the use of normal in the exam, for example:

HEENT normal

or do drs need to be more explicit, as in:
class one airway, poor dentation?

thanks!
Jenna

Normal is ok and I'd give credit for all (head, eyes, ears, nose and throat). It's the abnormal where they would need to go into more detail.

Just my 2 cents I know other coders would beg to differ.

 

[MikeEnos]

I agree with Tony. I don't see how anyone could differ, CMS is unambiguous on this.

According to CMS:

Some important points that should be kept in mind when documenting general
multi-system and single organ system examinations (in both the 1995 and the 1997
documentation guidelines) are:
❖ Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be documented.
A notation of ?abnormal? without elaboration is not sufficient.
❖ Abnormal or unexpected findings of the examination of any asymptomatic body
area(s) or organ system(s) should be described.
❖ 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).

So yes, as long as they aren't seeing the doctor for a problem with their Eyes, Earns, Nose, or Throat, you can give credit for the statement HEENT: normal as review of the Head, Eyes, and ENT. On the other hand, of the note says HEENT: PERRLA then they would only get credit for the eyes. I always advise providers to be careful when using acronyms like that. They should either break out Eyes separately or make sure they document findings of Eyes as well as the ENT to make sure they don't under-document their work.