ROS/Exam requirements

Lynda Wetter

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Is documentation for the ENMT area for ROS and/or ENT for Exam if the doc only mentions one of those for example...Negative for Tinnitus (ears) is that enough to give them that area as reviewed or examined?

Thanks, Lynda CPC
 

Lynda Wetter

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another example:
HEENT: Head is normocephalic, atrraumatic. Conjunctovae are pink, sclera is anicteric.

Is this enough to give the "points" for this exam? (1995 Guidelines)
 

btadlock1

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another example:
HEENT: Head is normocephalic, atrraumatic. Conjunctovae are pink, sclera is anicteric.

Is this enough to give the "points" for this exam? (1995 Guidelines)
Under 95 guidelines, you could either give credit for one body area (head), or one solid organ system eyes). I don't actually give credit for 'normocephalic/attraumatic', because it's not clear what they're talking about - the skin, muscles, bone structure? 'Normocephalic' doesn't sufficiently describe the Ears, nose, mouth, and throat, in my opinion.
 

btadlock1

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Is documentation for the ENMT area for ROS and/or ENT for Exam if the doc only mentions one of those for example...Negative for Tinnitus (ears) is that enough to give them that area as reviewed or examined?

Thanks, Lynda CPC
Yes - the guidelines don't state that all of the above have to be questioned, individually - they're all lumped together, so credit for one, counts for all 3, under ROS.
 

MnTwins29

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"Normocephalic"

Agree with you Brandi, for an organ system - but playing devil's advocate here and I KNOW I am going to have to explain this - could it be used as a body location (neck)? I wouldn't do so because I don't believe it is specific enough, but you know that not everyone will agree with that reasoning!

Thanks.
 
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Body area AND organ system

You would get credit for 1 body area (head) and one organ system (eyes)

HOWEVER ... if you are looking at a comprehensive exam ... you cannot count the body area at all, so you'd only get credit for examining the organ system "eyes."

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

Lynda Wetter

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Thanks I think all this did help and confirm what i was thinking. But, on the "normocephalic" when you break down thwe terminology dont you see it to be "normal head" normo-cephalic???

Thanks everyone!
 
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