btadlock1
Guest
Yes, I'm still on the same issue I've been on for a while now...To give a bullet, or not to give a bullet...that is the question! 
(I'll learn this eventually, I promise...)
So here are some phrases I'm having trouble deciding if/where to allow credit under 1997 guidelines. (I can't use 1995, so it's not really relevant here...) Please let me know what you think!
(Eye) "Extraocular movements intact" (I know I've asked on this one before, and I think the concensus was that it doesn't count, but now I'm not sure...)
"No chest wall tenderness" - This was under Respiratory, but would it count under M/S as examination of ribs?
(Under Neurologic) "Normal motor function. No focal defects" - This is just my theory (after seeing it several times), but I think that 'no focal defects' is actually supposed to say 'no focal deficits' - I usually see it paired with something like "Cranial nerves II-XII grossly intact", but sometimes it's by itself. (Outside of that context, though, I guess he could just as easily be referring to their attention span...See - this is how I confuse myself...)
(Under CV) "Good pulses equal in all extremities." - Pedal pulses, maybe?
(Under GI) "Non-distended" - is it too much of a reach to count this as an examination of liver/spleen? Sometimes I'll see it with "no organomegaly", but not always...Isn't abdominal distention typically associated with liver/spleen problems? I don't want to nit-pick, but does it have to be more specific than "non-distended" to count for anything? (aside from examination of abdomen with notation of presence of masses/tenderness - that bullet had already been met elsewhere)
And one more question...under 1997 guidelines, as most of you know, there are the single-OS exams, and the general multi-system exam. All of the guidance I've been able to find says that the single OS exams were designed for specialists, but that anyone can use them. What I can't seem to find, is whether you can use bullet criteria from a Single OS exam with the Multi-system exam...
Some of the bullets that I think my providers are going for aren't on the multi-system exam, but they are scattered throughout the single OS bullets. How does that work? Can I mix and match with the multi-system exam, or is it strictly "what you see is what you get", with the bullets available?
For example: I've got the phrase "Speech clear and coherent. Functional cognition intact."
Under the Single OS Psychiatric exam, that's worth 2 bullets - Description of speech, and description of thought processes. Those bullets don't exist under the Multi-system exam. Can I still count them???
(I'll learn this eventually, I promise...)So here are some phrases I'm having trouble deciding if/where to allow credit under 1997 guidelines. (I can't use 1995, so it's not really relevant here...) Please let me know what you think!
(Eye) "Extraocular movements intact" (I know I've asked on this one before, and I think the concensus was that it doesn't count, but now I'm not sure...)
"No chest wall tenderness" - This was under Respiratory, but would it count under M/S as examination of ribs?
(Under Neurologic) "Normal motor function. No focal defects" - This is just my theory (after seeing it several times), but I think that 'no focal defects' is actually supposed to say 'no focal deficits' - I usually see it paired with something like "Cranial nerves II-XII grossly intact", but sometimes it's by itself. (Outside of that context, though, I guess he could just as easily be referring to their attention span...See - this is how I confuse myself...
)(Under CV) "Good pulses equal in all extremities." - Pedal pulses, maybe?
(Under GI) "Non-distended" - is it too much of a reach to count this as an examination of liver/spleen? Sometimes I'll see it with "no organomegaly", but not always...Isn't abdominal distention typically associated with liver/spleen problems? I don't want to nit-pick, but does it have to be more specific than "non-distended" to count for anything? (aside from examination of abdomen with notation of presence of masses/tenderness - that bullet had already been met elsewhere)
And one more question...under 1997 guidelines, as most of you know, there are the single-OS exams, and the general multi-system exam. All of the guidance I've been able to find says that the single OS exams were designed for specialists, but that anyone can use them. What I can't seem to find, is whether you can use bullet criteria from a Single OS exam with the Multi-system exam...
Some of the bullets that I think my providers are going for aren't on the multi-system exam, but they are scattered throughout the single OS bullets. How does that work? Can I mix and match with the multi-system exam, or is it strictly "what you see is what you get", with the bullets available?
For example: I've got the phrase "Speech clear and coherent. Functional cognition intact."
Under the Single OS Psychiatric exam, that's worth 2 bullets - Description of speech, and description of thought processes. Those bullets don't exist under the Multi-system exam. Can I still count them???
Last edited:
