I think that all of the alternative documentation you mentioned in your thread would be appropriate bullet items. The intent is not to have a "cookie cutter" chart, but to document the areas/organ systems and the various items within those systems in a way that identifies an appropriate exam. It's up to the coder to understand the many terms that would constitute the exam bullets, so that she/he is not depending on the provider to document word-for-word chart notes just to satisfy the bullet requirements. Use your Taber's or other medical dictionary if you are unsure of the terminology. Pam Brooks, CPC
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