tci ED Coding & Reimbursement Alert - 2022 Issue Q1

Reader Questions: Count the Elements for Physical Exam

Question: Sometimes I’m coding a chart and can’t decide how to classify the documentation of a physical exam element. Most are pretty straightforward, 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 mix in body areas as well towards the required 8 systems for a comprehensive exam. Do you agree with my 7 systems? Physical Exam: Gen:...

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