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Physical Exam?

  1. #1
    Default Physical Exam?
    Medical Coding Books
    Our Dr. uses a Template for his PE... it has each system on it and certain bullets. problem is that he does not check off a bullet point on some of the systems he writes NO ABNORMAL FINDINGS...So does this count as a bullet??
    IS this compliant ?? does anyone else use a template like this . Your feed back would be greatly appreciated.

  2. Default
    A brief statement or notation indicating "negative" or "normail" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ systems.

    We use 97 guidelines

    God I wish I could remember which reference book this is from! Hope it helps!

  3. #3
    This statement is included in the 97 guidelines:

    Go to page 13 (in the box on top), if you scroll down it is on page 11 - look for DGs, it's the third DG.

    Hope this helps.
    Karolina, CPC, CPMA, CEMC

  4. #4
    Wonderful wonderful... Thank you so much for the info and reference info

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