Review of System or Exam Element

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March 15, 2012

Question:

I am so excited! I have recently passed my certification as a coding auditor and have taken on a new job doing nothing but audits. I am reviewing an office note and have a question related to a statement in the note. The surgeon documented “Neck is supple, no JVD or lymphadenopathy.” I am not sure where to give credit for these statements in the Review of Systems. I know I can give credit for skin and lymphatic but not sure if I am capturing everything. Can you assist me?

Answer:

Congratulations on your new coding certification! Based on the information you provided, it appears that these statements are not related to a Review of Systems but are actually findings from a physical exam. Credit would be counted as “elements identified by a bullet” in the 1997 Multi-System Exam and not the Review of Systems. However, without the full note it difficult to advise 100%. Review the entire note again and re-code it and see what you think.