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