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Physical Exam ?

  1. #1
    Question Physical Exam ?
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    Good Morning..I would like some input if anyone has any-I have a phy who puts "EXTEMITIES: edema: none. Pulses: radial, dorsalis pedis, posterior tibialis, 3+/3" and using this under MS. Should this information not be considered Cardio? Thanks for your help!!

  2. #2
    Minneapolis MN
    You are correct, they are are listed under the Cardiovascular section of the 1997 Examination elements; as a coder, I count them under the CV section and not MS section, even though they are documented under the MS section. Sometimes we need to make those adjustments. Kind of the same strategy as pulling HPI elements from a note that has CC, HPI, ROS, and hx all lumped together- we use our coding skills to divide and conquer! I would send your provider a message with your concerns - if s/he changes, great, if not, just count them in the system/body area they are from.

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