HEENT "Normal"

Hi,

What credit is given under '95 and '97 exam DG when a provider documents HEENT Normal?

Thanks so much for any information you can give.

Deb

HEENT normal

Neither the 1995 nor the 1997 Documentation Guidelines provide this level of detail, so consultants and auditors have opinions, but can't point to a CMS reference.

I personally don't credit anything in the 1997 exam for HEENT normal. I just don't know: what did the clinician look at?

For the 1995, I will give head for a body area, but none for eyes or ears, nose, mouth, throat. Again, I just can't be sure. Was anything looked at?

opinions

http://www.aafp.org/online/en/home/publications/journals/fpm/collections/fpmmedicare/examdoccharting.html.
Also:
For purposes of examination, the following body areas are recognized:
? Head, including the face
? Neck
? Chest, including breasts and axillae
? Abdomen
? Genitalia, groin, buttocks
? Back, including spine
? Each extremity

For purposes of examination, the following organ systems are recognized:
? Constitutional (e.g., vital signs, general appearance)
? Eyes
? Ears, nose, mouth and throat
? Cardiovascular
? Respiratory
? Gastrointestinal
? Genitourinary
? Musculoskeletal
? Skin
? Neurologic
? Psychiatric
? Hematologic/lymphatic/immunologic?

Which means that HEENT = Head, Eyes, Ears/Nose/Throat. It goes on to say?

?The extent of examinations performed and documented is dependent upon clinical judgement and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

HEENT-normal

According to '95 d/g "A brief statement or notation indicating"negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)." All we as coders have, to support what was done in the exam is in the written word. If the provider stated HEENT-normal, he/she is identifying the Head (Body area), Eyes (Organ system) and ENT (Organ system) are normal. We are not the judge of whether the provider did the exam. Providers are using abrev to note what was done. '97 d/g requires specific documentation and the documentation of HEENT-normal can not be applied.