Sandy Posted Thu 24th of September, 2015 14:14:49 PM
Can you please explain when normal vs. abnormal findings will be used as a diagnosis for a physical exam-this is confusing to my physicians-
SuperCoder Answered Mon 28th of September, 2015 05:00:25 AM
Well, while performing physical exam, there should be listing of physician's findings in every (or examined organ system/body areas) organ system/body areas, these readings final contribute to make higher level of visit accordingly. While examine the patient if some readings/tests are normal, so it does'not mean that it will not counted, it will be counted as physician put his/her efforts to perform the organ system examination. And if there are abnormal findings, it will be counted as points to PE and will add the diagnosis to the patient, which is very helpful to support the medical necessity to the patient's record. Hope this clear you doubt!