Wiki how to count this statement in the exam

[SueTeal]

if a doctor documents, 'mucous membranes are moist', can this be counted for inspection of nasal mucousa AND exam of oropharynx using the 1997 documentation guidelines? What about HEENT exam normal? I try to think about how 'government auditors' might count this. In my opinion, I would give ONE credit for either but provide education to the provider to be clearer with one or two more words about where the moist mucousa is and what in the HEENT was normal. I would NOT give credit for each element within the body systems. I appreciate other's opinions. Thank you.

 

[rlohearn]

I tend to agree with you, Sue, but I also tend to be a very conservative auditor. Some of that is because I'm new at the auditing end of it, but some of it is for the very reason you mentioned above--trying to think of it from a gov't perspective. I would expect any external auditor to not be as generous as internal auditors like to be toward providers.