What documentation is required under the 1997 guidelines if a provider states "cardiovascular normal, respiratory normal"?

Under the 1997 guidelines, if a provider documents findings as "cardiovascular normal, respiratory normal," it indicates limited information regarding the patient's condition. The documentation does not provide sufficient detail to support a complete examination. In evaluation and management coding, the necessity for comprehensive documentation is crucial. A "bullet" in this context refers to the assessment of specific body systems as part of a review of systems or examination where detailed findings should be noted to fulfill the criteria for the coding of services.

In this case, the statement reflects a basic conclusion rather than an exhaustive examination of the systems in question. Therefore, because the documentation lacks the depth and specificity required to assign a bullet, it is correctly stated that no bullet can be assigned. Not having a bullet means that the examination does not meet the necessary criteria established by the 1997 guidelines for that level of service. This emphasizes the importance of thorough and detailed documentation to justify the medical decision-making and the level of service provided.