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Question: Encounter notes indicate that a patient presented with stroke-like symptoms, and the neurologist performed a “neurologic exam.” When the provider performs a neurologic exam, what are the components?

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Answer: Anyone who presents with stroke symptoms needs immediate attention in order to prevent further deterioration. In general, the neurologist will conduct a stroke-centered examination on any patient presenting with acute neurologic deficit or any alteration in level of consciousness, said Leigh Poland, RHIA, CCS, CDIP, CIC, AHIMA Approved ICD-10-CM/PCS Trainer, and vice president of the Coding Services Line at AGS Health.

“The physician must be able to perform a brief but accurate neurologic examination on patients with suspected stroke syndromes,” Poland explained during her HEALTHCON 2025 presentation “Unlocking the Full Potential of Stroke Coding and Documentation.” The neurologist conducts the neurologic exam to:

• Confirm the presence of stroke symptoms (neurologic deficits)
• Distinguish stroke from other stroke-like conditions
• Establish a neurologic baseline should the patient's condition improve or deteriorate
• Establish stroke severity if a stroke is identified using a structured neurologic exam and National Institutes of Health Stroke Scale (NIHSS) to assist in prognosis and therapeutic selection

As a coder, it’s up to you to select the appropriate CPT^® and ICD-10-CM codes to reflect the neurologic exam based on encounter notes. But be careful: whether the stroke is ischemic or hemorrhagic, common stroke signs and symptoms are often the same — but not always.

And though you might get a stroke patient with a single stroke indicator, the symptoms are more likely to occur in combination. “No historical feature distinguishes ischemic from hemorrhagic stroke, although nausea, vomiting, headache, and sudden change in level of consciousness are more common in hemorrhagic strokes,” said Poland. “In younger patients, a history of recent trauma, coagulopathies, illicit drug use, migraines, or use of oral contraceptives should be elicited.”

Chris Boucher, MS, CPC, Senior Development Editor, AAPC