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Exam "HEENT: unremarkable"

  1. #1
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    Default Exam "HEENT: unremarkable"
    Medical Coding Books
    I am needing help on this issue as I am currently getting together a list for provider education. Can anyone help me with how this would be counted in the Exam portion of an E/M? I've been trying to find documentation to back up my gut and just not finding it anywhere.

  2. #2
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    Quote Originally Posted by pammalou View Post
    I am needing help on this issue as I am currently getting together a list for provider education. Can anyone help me with how this would be counted in the Exam portion of an E/M? I've been trying to find documentation to back up my gut and just not finding it anywhere.
    I'd give 1 for head under BA, 1 eyes and 1 ENMT under OS.

    As per Novitas E&M guidelines;DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

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