by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
June 13th, 2019
According to Neurology Clinical Practice and NBIC, the neurologic exam is commonly lacking in documentation due to the extensive requirements needed to capture the appropriate revenue.
With the lack of precise documentation, it results in a lower level of E/M than that which is more appropriate, which can cost a physician a lot of lost revenue. The E/M Evaluation and Management codes are based on medical complexity or time spent on care. The 1997 guidelines were revised to include a new general multi-system examination and several single organ system examinations, one of which is neurology.
The clinical neurology exam has 25 elements with 22 neurologic exam findings. This also includes 3 elements of the cardiovascular examination. If any part is omitted or there is not one cardiology element reported, then the comprehensive examination cannot be reported and you must drop it to the next level down. For the Cardiology element to be complete you only need 1 element to report a comprehensive exam using 99222 or 99223, however, you can report 1-3 elements.
97 Guidelines for Neurology E/M Exam
Neurological Evaluation of higher integrative functions including:
Test the following cranial nerves: