Is the information on the general multi-system exam worksheet set in stone? Meaning, the information that it allows for counts and anything else does not count?
Example:
Vital Signs: ?*Temperature: Reviewed. ?*RR: Reviewed. ?*PR: Reviewed. ?*Blood pressure: Reviewed.
General Appearance: ?*Normal. ?*Well developed. ?*Well nourished. ?*In no acute distress.
Head: Injuries: ?*No evidence of a head injury. Appearance: ?*Head normocephalic.
Psychiatric: Mood: ?*Euthymic. Affect: ?*Normal.
Skin: ?*Skin: 4cm incision on lateral right anterior shin healing, well-approximated edges. No erythema or exudate. Mild surrounding swelling.
According to the sheet, the exam would receive 4 points.
1- Constitutional
2- General Appearance
3- Skin
4 - Psychiatric
That leaves the "Head." Does the provider not get any credit for the head?
Last question: If the exam of a system, say cardiovasular: When it says "Ausculation of heart with notation of abnormal sounds and mumurs.
If the provider documents that ausculation of the heart had no abnormal sounds and no mumurs. Since there is no findings of abnormal would the provider not get credit for this aspect of the cardio exam?
Thank you
__________________
Christopher J. Halk, CPC
Coding Auditor
Sterling Medical Corporation
Kunsan Air Force Base
Republic of Korea
Exam 2 questions
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