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Exam: System or body part?

  1. #1
    Location
    Ellenville, New York
    Posts
    1,176
    Default Exam: System or body part?
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    Two common entries for the exam by our docs is giving me fits - not sure whether to count as a system or body part - which as you know can make a big difference!

    Abdomen: soft, tender, normal bowel sounds - my hunch is body part

    Neck: no lymphadenopathy (or mild, etc.) - my hunch is system, since lymph nodes are documented.

    Thoughts? Aside from that I am crazy???

    Thank you.

    Lance

  2. #2
    Default
    Quote Originally Posted by MnTwins29 View Post
    Two common entries for the exam by our docs is giving me fits - not sure whether to count as a system or body part - which as you know can make a big difference!

    Abdomen: soft, tender, normal bowel sounds - my hunch is body part

    Neck: no lymphadenopathy (or mild, etc.) - my hunch is system, since lymph nodes are documented.

    Thoughts? Aside from that I am crazy???

    Thank you.

    Lance
    Hahaha...you sound like you have the same EMR prompts my providers do! We use 97 guidelines, so here's how I credit these:

    Abdomen: One bullet under GI for examination of abdomen (mass/tenderness/etc.) - normal bowel sounds is not a bullet.
    "No lymphadenopathy" doesn't get credit, because the bullet requires at least 2 specific lymph areas to be documented, and that's a vague statement.

    Under 95 guidelines, I'd give credit for organs systems: GI and Lymph.

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default Thanks - we use 95 guidelines...
    at least for our family practices, which are the ones that use these prompts frequently, hence the line of questioning. On the abdomen, I just felt that without mention of an organ (which sometimes happens - "bowel sounds" not always documented), I would count as body part. Ah, the joys of E/M coding.

    Thanks for the e-mail as well!

    Lance

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