BC Advantage - 2017 Issue 3
Weekly Auditing and Compliance Tip
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Article Overview
This article is a practical auditing tip for readers who review multispecialty encounters and want a clearer understanding of neurologic exam terminology. It discusses broad categories of neurologic assessment such as reflex testing, coordination testing, and gait evaluation, with emphasis on how these concepts may appear in documentation across specialties. The piece is aimed at auditors and compliance staff who need to interpret specialty-specific language during E&M review.
Why This Topic Matters
Neurologic terminology can make documentation review more challenging when audits span multiple specialties. This tip helps readers become more comfortable recognizing common exam language so they can better evaluate encounter notes and context.
Article Sections
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Neurologic Reflex Testing
Introduces reflex assessment in neurologic examination and explains the general grading framework used to describe reflex findings. Also notes related terminology used in clinical documentation.
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Coordination Testing
Reviews common coordination assessment language used in neurologic exams and the broad purpose of these tests. The section describes typical types of coordination tasks clinicians may document.
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Gait Testing
Covers gait observation as part of neurologic or musculoskeletal assessment and outlines general categories of gait findings. The section also places these observations in the broader context of patient movement and balance.
What You Will Learn
- How neurologic exam terminology may appear in audit documentation
- The broad purpose of reflex, coordination, and gait assessments
- Why specialty-specific language matters in multispecialty encounters
- How auditors can better interpret common exam wording in clinical notes
Who Should Read This
- Medical auditors
- Compliance staff
- E&M reviewers
- Coding professionals working across specialties
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