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Thread: abdominal exam documentation element

  1. #1

    Default abdominal exam documentation element

    AAPC: Back to School
    Hello everyone,
    The question is, is it appropriate to give credit (bullet) for the abdomen palpation portion if the physician states "abdomen soft" only?
    Thank you,

  2. #2


    I wouldn't. Maybe if it stated "soft and nontender" I definitely would. Maybe you should query the provider.

    The examination of abdomen bullet states "notation of presence of masses or tenderness" soft is nice, but doesn't quite fit.

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