Case 1-EM 2
The physical exam portion documents clear findings under the following headings (I’ve listed the organ system I associated to each in parenthesis):
Head and Neck-(Musculoskeletal)
Thyroid (Lymphatic)
Lungs (Respiratory)
Heart (Cardiovascular)
Abdomen (GI)
Breasts, Pelvic, Vulva, Cervix, Vagina, Uterus, Adnexa-(GU)
However, this is where I think I may be confused…
The BP is documented (Constitutional)
Then it shows General-WNL, no apparent acute distress
Does "no apparent acute distress" not account for the Psychiatric? The rationale states the exam, according to 1995 guidelines, is detailed due to detailed findings in 2-7 body areas/organ systems. I’m guessing I am misinterpreting the distress as part of the Psychiatric instead of General Appearance under Constitutional. However, I don’t understand why this wouldn’t count as "Mood and Affect" which includes descriptors such as anxiety and agitation.
Case 2-EM 5
The physical exam portion documents clear findings under the following headings (I’ve listed the organ system I associated to each in parenthesis):
Integument (Skin)
Ears, Nose/Sinus, Throat/Mouth (ENMT)
Lungs (Respiratory)
Heart (Cardiovascular)
Abdomen (GI)
Head (Musculoskeletal)
General-A&O x3, no acute distress (Psychiatric)
This is where I think I’m missing something:
The HT, WT, and Temp are documented in the note, but underneath the HPI and not in the actual PE part of the note. Can those vitals still be counted as part of the Constitutional? The note doesn’t specifically state one way or another whether or not the actual physician took the vitals or if it was the tech/MA…
With that being said, it is also documented under Neck, "Supple without Lymphadenopathy". Therefore, can you not count the "without Lymphadenopathy" as part of the Lymphatic system instead of grouping the neck with the Musculoskeletal? The 1995 guidelines (which were used in the rationale) only state that for the comprehensive general multi-system examination, it only has to include "findings about 8 or more of the 12 organ systems".
The note clearly documents findings in 7 systems. Therefore, the Constitutional or the Lymphatic would make 8 (or 9), but the rationale for the note is that it is a Detailed exam based on 1995 guidelines due to detailed findings in 2-7 body areas and/or organ systems.
Can someone explain where I am wrong (or maybe right??) in my justification? This is driving me crazy!!
Dawn Wachtel, CPC, CPB