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help needed with auditing a pediatrician

  1. Default help needed with auditing a pediatrician
    Medical Coding Books
    I am new to auditing E/M coding for a pediatrician, and I need help please!

    When my pediatrian documents under physical examination "no meningeal signs" do I give him credit under neurologic? But for what element of examination, test cranial nerves with notation of any deficits, or examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski), or examination of sensation (e.g. by touch, pin, vibration, proprioception). I have searched on the Internet, but can't find a clear answer. Can anyone help please?

  2. #2
    Default Ped coding
    Being new I think you are over thinking it. Just count it for 'one'. E/M wise you are counting. You are not having to decifer it. I code Ped's too.

  3. Default
    1995 Neuro
    1997-- give him the bullets and have him tell you--- then perhaps offer him a template that may help to differentiate his exam.

  4. Default
    Thank you both for your replies. I sure do appreciate your help.

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default 1995 guidelines
    In general I find the 1995 guidelines much better for pediatrics. I mean you can't do a pelvic on a 9-month old (nor typically a digital rectal exam, or breast exam, or ...)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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