FAQ #17
       
Can you say, "unremarkable" or "within normal limits" for exam systems and get credit?

Answer: The answer is "yes" and "no".

The 1995 and 1997 E/M guidelines contain the following documentation guidance:

• Specific abnormal and relevant negative findings of the examination of the
  affected or symptomatic body area(s) or organ system(s) should be
  documented. A notation of "abnormal" without elaboration is insufficient.
  
  
• Abnormal or unexpected findings of the examination of the unaffected or
  asymptomatic body area(s) or organ system(s) should be described.
  
  
• 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).

1995 E/M guidelines: p. 10. 1997 E/M guidelines: p. 13

This seems to indicate that abnormal findings must be explicitly documented, but that normal findings may be recorded using the terms "negative" or "normal."