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Documentation of E/M services for Neurology (Don't Forget the Cardiology Element)

By:  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Published:  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:

  • Orientation to time, place and person
  • Recent and remote memory
  • Attention span and concentration
  • Language (eg, naming objects, repeating phrases, spontaneous speech)
  • Fund of knowledge (eg, awareness of current events, past history, vocabulary)

Test the following cranial nerves:

  • 2nd cranial nerve (eg, visual acuity, visual fields, fundi)
  • 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements)
  • 5th cranial nerve (eg, facial sensation, corneal reflexes)
  • 7th cranial nerve (eg, facial symmetry, strength)
  • 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub)
  • 9th cranial nerve (eg, spontaneous or reflex palate movement)
  • 11th cranial nerve (eg, shoulder shrug strength)
  • 12th cranial nerve (eg, tongue protrusion)
  • Examination of sensation (eg, by touch, pin, vibration, proprioception)
  • Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (eg, Babinski)
  • Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)

Cardiovascular

  • Examination of carotid arteries (eg, pulse amplitude, bruits)
  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be
    measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages) 

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf


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