Aledford
Networker
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...
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...