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Click here for more sample CPC practice exam questions and answers with full rationale

GI versus Abdomen using 95 Guidelines

I’m confused as to what elements GI needs to have to count it as an organ system versus a body area using 95 Guidelines. We are being told that this system/area only counts as GI if states bowel sounds. If the provider doesn’t document bowel sounds, we have to count it as a body area and not the organ system.

Example

General: Pleasant, NAD, sitting in a chair
HEENT: EOMI; no scleral icterus; MMM
Lungs: decreased breath sounds
CV: RRR,
GI: soft, NT/ND; no guarding or rebound
Extremities: WWP, No LE edema
Neuro: AAOx3; no asterixis
Skin: warm; no jaundice
Psych: Normal mood/affect

According to what we are being told, GI would not be counted as a system but rather a body area. Help would be greatly appreciated. Thanks

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