Wiki normocephalic as an organ system?

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stpat

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We have an outside auditor come in roughly every six months to audit a sample of E/M charts for each doc. In her findings for the exam, and based on 95 guidelines, she counts normocephalic as an organ system under musculoskeletal because she said it is considered the skull. I don't agree with that and count it as a body area, so my findings don't consistently match up with hers. Am I being too rigid in my coding? Does anyone else count this as an organ system? :confused:
 
I would count it as MS as well. If they just say "Head:WNL" or something to that affect, I would only count it as a body area.

I base this on the 97 guidelines and where they assign credit for similar statements.

That is the unfortunate side of using 95, it is not well defined and different auditors will come up with different interpretations.

Laura, CPC, CPMA, CEMC
 
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