Eye: Extraocular movements are intact - NO bullet under Eyes. This is a measure of cranial nerves, so would fall under Neuro in 1995 guidelines. 1997 just has "test cranial nerves with notation of any deficits" ... I might give credit for 1 bullet here, but usually we see documentation of All the cranial nerves II-XII.
HENT: Normocephalic - NO bullets under 1997
Neck: Non-tender, no lymphadenopathy - 1 bullet for "examination of neck (e.g. masses, overall apperance, symmetry, tracheal position, crepitus)
Psych: Cooperative - no bullet, though I might be persuaded to count this as Constitutional for general appearance.
If they are going to use 1997 guidelines exclusively, your providers REALLY need to look at the audit sheet for the 1997 guidelines and learn to document to specifically meet the bullet points listed there.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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