Examination "No acute distress"

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Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Tue Feb 20, 2018 8:55 am

I have a physician that wants credit for 8 organ systems on his examination of a patient that is in his office for recurrent Dupuytren's disease of finger, with contracture. He is recommending regional fasciectomy. I can get to moderate acuity, complete HPI, but I am not sure about comprehensive organ system. He is wanting to count the "no acute distress" as a psychiatric finding, and I can see the logic behind this. But, I would like some other opinions.

His physicial exam reads: no acute distress alert & oriented x 3 moist mucous membranes PERRLA gait within normal limits skin without rash respirations nonlabored. (I have typed this as it is on the note) He also has >3 vital signs listed on the chart.
I see vital signs = constitutional, alert & oriented x 3 = neuro, moist mucous membranes = HENT, PERRLA = eyes, gait within normal limit= musculo, skin without rash= skin, respirations nonlabored = respiratory and the infamous no acute distress= psychiatric. This would give him 8 body systems.

If you feel "no acute distress" should not be counted, please support with reasons so I can go back to the physician and explain.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
pedscoder
Posts: 23
Joined: Wed Jun 03, 2015 10:18 am

Tue Feb 20, 2018 12:26 pm

We count "alert & oriented x3" as psychiatric (which is in your exam example), since "orientation to time, place, person" is part of the psychiatric exam on the 1997 guidelines.
Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Tue Feb 20, 2018 3:46 pm

So there would still only be 7 systems since I was using it as Neuro. If I changed that to psychiatric, I still only have 3 as NAD counts as psychiatric also.

The 1997 Neurological examination (single organ system exam) lists Orientation to time, place and person under Neurological findings.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
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