? Exam

Aledford

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Hello...
I am just reaching out for a little help regarding an Exam. 2 Coders are not agreeing on level and documentation {imagine that!}
After first looking at this exam I feel it might be detailed or Expanded problem focused, but not a Comprehensive. Please coders give input...

General: of aching no distress_
Eye: _ no encounter Pupils equal and reactive
Neck: _ soft no JVP
Respiratory: _ no respiratory distress no crackles no wheezing or rhonchi
Cardiovascular: _ regular normal S1-S2 no murmur no friction rub
Gastrointestinal: _ soft no distention or tenderness bowel sounds present no rebound
Neurologic: _ alert oriented x3 no focal neurologic deficits power upper and lower extremities 5/5. Sensation is intact
Psychiatric: _ appropriate mood and affect


I see 7 systems and 1 body area... However it is the opinion of one coder the statement power upper and lower extremities 5/5 can be pulled out of Neurological and counted as part of a Musculoskeletal exam.. I do not agree. It seems this should stay apart of the neurological due to this seems more and exam of nerves in the extremities, just my opinion. Let have a discussion about this! Please help...
 

Pathos

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As amla12 suggested, always go back to the basic/core guidelines when you hit a snag.

I get 11 exam elements (Expanded Problem Focused) using 1997 guidelines with either the General Exam or Musculoskeletal, since I put "no distress" under Psych (Mood/Affect) instead of Constitutional (General Appearance).

If the provider is thinking muscle strength when dictating "power", he/she might want to improve their documentation a little to remove any confusion. I have seen plenty of exam dictations where the elements are all over the place, but can still be counted. However, if the auditor if any documentation is unclear, the auditor will likely not give credit for that piece of documentation.

I'd gladly elaborate on my findings through PM if interested, but I definitely don't see a Comprehensive Exam (unless you use 1995 guidelines) and not even a Detailed in the note you shared.

Hope that helps!
 

Aledford

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Thank you both for your suggestions.... Yes if you would please message me. This was coded using 1995 {which I feel can sometimes be a grey area for coders} I would like your thoughts on how you obtained a level using 1995 guidelines. As I stated I am not seeing a comprehensive exam.
 

amla12

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"Power" means testing for muscle strength, if that helps. Standard terminology that should not confuse an auditor.
 

Aledford

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Thank you amla12... I still feel if the provider is stating this as regards to Musculosketetal then they should be putting it under the correct header. Grouped into a neurological header is just causing confusion among coders. I get your statement that a seasoned auditor would gather from "power" that they are referring to muscle strength. However a new coder might overlook this. As we all know not all coders thing alike what one might assume is MS others might not.
 
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