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abdominal exam documentation element

  1. Default abdominal exam documentation element
    Medical Coding Books
    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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