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Please audit this exam

  1. #1
    Location
    Kansas City, MO
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    92
    Default Please audit this exam
    Medical Coding Books
    If the physician documents:
    Physical Exam
    Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.

    How many points would this be and what organ systems and/or body areas would you assign this to?

  2. Default
    I would count:
    supple under Musculoskeletal
    no JVD, no carotid bruits under Neck
    no lymphadenopathy under Lymphatic

    3 total for an EPF exam

    Hope that helps.

    Kelsey, CPC

  3. #3
    Default
    Quote Originally Posted by PRICEOR View Post
    If the physician documents:
    Physical Exam
    Neck: Supple, no JVD, no carotid bruits, no lymphadenopathy or thyromegaly.

    How many points would this be and what organ systems and/or body areas would you assign this to?
    I see these statements all of the time - I give it 3 bullets:

    Supple is 'examination of neck' bullet
    'No cartoid bruits' falls under a cardiovascular bullet
    and 'no thyromegaly' is under neck, examination of thyroid.

    The jugular vein isn't listed as a bulleted exam element, so it gets no credit, and "no lymphadenopathy" is too vague to meet the minimum requirements of the lymphatic system's bullet, which requires the examination of at least 2 lymph node areas; the neck is only one.

    Hope that helps!

  4. #4
    Location
    Kansas City, MO
    Posts
    92
    Default
    Thanks for responding!

    I would normally give this statement credit for 3 systems/areas:
    Neck - Supple, no thyromegaly
    Cardiovascular - no JVD, no carotid bruits
    Lymphatic - no lymphadenopathy

    But I recently received an opinion that if the doctor uses the heading "neck" you should only count that as 1 body area no matter what is said.

    Any opinions on this??

  5. #5
    Default
    Quote Originally Posted by PRICEOR View Post
    Thanks for responding!

    I would normally give this statement credit for 3 systems/areas:
    Neck - Supple, no thyromegaly
    Cardiovascular - no JVD, no carotid bruits
    Lymphatic - no lymphadenopathy

    But I recently received an opinion that if the doctor uses the heading "neck" you should only count that as 1 body area no matter what is said.

    Any opinions on this??
    I don't agree with that - things are mislabeled in notes all of the time, and the doctor doesn't have to label anything, really - I typically only use 1997 guidelines, but if you're going by 1995, then I'd say you've got it right!

  6. #6
    Location
    Kansas City, MO
    Posts
    92
    Default
    I agree!!

    Thanks!

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