Wiki Physical Exam Question

[LindsayC]

I am studying for the CEMC exam. I have noticed quite a few examples in the physical exam stating:

Lymphatic: no lymphadenopathy OR
Lymph nodes: no significant peripheral adenopathy

In the examination guidelines it states lymphatic must document the palpation of lymph nodes in two or more areas.

The physical exam note is confusing me, because the examples are noting them as a system reviewed, but it is not noting what 2 areas they are reviewing.

Can someone clear this up for me?

Thanks in advance

 

[willjv]

If using the 1997 documentation guidelines, you are correct that two or more areas (neck, axillae, groin, other) must be palpated and documented. Under the 1995 documentation guidelines, there is no specification as to how many lymph nodes must be palpated. If one is palpated and documented, credit is given for the lymphatic system. When auditing, use whichever set of guidelines benefits the provider the most. Either 1995 or 1997 can be used, as long as you do not "mix and match" between the two (e.g. HPI under 1997 allows for status of 3 chronic conditions but 1995 does not contain that verbiage).