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Physical Exam ?

medicode3

Networker
Messages
73
Best answers
0
Good Morning..I would like some input if anyone has any-I have a phy who puts "EXTEMITIES: edema: none. Pulses: radial, dorsalis pedis, posterior tibialis, 3+/3" and using this under MS. Should this information not be considered Cardio? Thanks for your help!!
 

gailmc

Networker
Messages
84
Location
Shoreview, MN
Best answers
0
You are correct, they are are listed under the Cardiovascular section of the 1997 Examination elements; as a coder, I count them under the CV section and not MS section, even though they are documented under the MS section. Sometimes we need to make those adjustments. Kind of the same strategy as pulling HPI elements from a note that has CC, HPI, ROS, and hx all lumped together- we use our coding skills to divide and conquer! I would send your provider a message with your concerns - if s/he changes, great, if not, just count them in the system/body area they are from.
 
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