tci ED Coding & Reimbursement Alert - 2016 Issue 6

You Be the Coder: Is That Physical Exam Element an Organ System or a Body Area?

Question: Sometimes I’m coding a chart and can’t decide how to classify the documentation of a physical exam element. Most are pretty straight forward, like “lungs clear” for respiratory or “normal bowel sounds” for abdomen, but how do you count vague statements like “neck supple” or “abdomen soft”? Here is a chart of a physical exam I recently coded. I only found 7 organ systems and can’t count body areas towards a comprehensive exam. Do you agree with my 7 systems? Physical Exam: Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)Head:...

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