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1995 exam question

  1. #1
    Location
    Ellenville, New York
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    1,176
    Default 1995 exam question
    Medical Coding Books
    I have heard conflicting views on this, so I made an executive decision and have been consistent on this. If using the 1995 guidelines for the exam, and under neck, there is documentation concerning lymphadenopathy, would you count this as the lymphatic system? I have heard that this should be done, and also heard it shouldn't and instead count the neck as a body part. This could be crucial if this can become a comprehensive exam, as you would need 8 SYSTEMS, not body parts.

    For the record, I always count this as a system - whether or not it will affect the determination of a comprehensive exam.

    I would like to hear others' practice, opinions, etc. Thank you.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  2. #2
    Location
    Daytona Beach, FL
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    742
    Default
    When I audit a chart and under Neck they mention Lymphadenopathy I use that towards the lymph system - also if they mention anything about the Thyroid too. Just because it is listed under a "body area" does not mean that it can't be applied to an organ system. Both body areas and organ systems can be inter-mixed for bullets - you just can't add them together to come up with your level. For example - Chest - if they mention examination of breasts - that is also Integumentary. Abdomen - if they mention organmegaly, or bowel sounds, that is GI....etc. Now if they don't document something under those headings that can apply to an organ system, then I don't give them credit for that - i.e under Neck they only mention no JVD or under Chest they simply say symmetrical, then there is only credit under Body areas, not organ systems. I never base the exam on the "label" the doctor uses as to whether it is a body area or system - only on what it is exactly that they have documented.

    Hope this helps in your poll!!
    Jodi Dibble, CPC

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default
    Quote Originally Posted by jdibble View Post
    When I audit a chart and under Neck they mention Lymphadenopathy I use that towards the lymph system - also if they mention anything about the Thyroid too. Just because it is listed under a "body area" does not mean that it can't be applied to an organ system. Both body areas and organ systems can be inter-mixed for bullets - you just can't add them together to come up with your level. For example - Chest - if they mention examination of breasts - that is also Integumentary. Abdomen - if they mention organmegaly, or bowel sounds, that is GI....etc. Now if they don't document something under those headings that can apply to an organ system, then I don't give them credit for that - i.e under Neck they only mention no JVD or under Chest they simply say symmetrical, then there is only credit under Body areas, not organ systems. I never base the exam on the "label" the doctor uses as to whether it is a body area or system - only on what it is exactly that they have documented.

    Hope this helps in your poll!!
    Thanks, Jodi - you and I think along the same lines for body area vs. system. We use strictly 95 guidelines so the bullets are not an issue, but I practice many of the same points you make - integumentary if breast exam is mentioned, bowel sounds = GI system, etc.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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