Neurology & Pain Management Coding Alert

Question: Our neurologist often dictates "Cerebellar Exam: No dysmetria or dysdiadochokinesia observed" in her new patient documentation. In the 1997 neurological examination, I don't see cerebellar exam listed under any of the bullets. Where should I give credit for this?

New Jersey Subscriber

Answer: You are correct in that the 1997 Documentation Guidelines for Evaluation and Management Services do not list cerebellar exam as a specific bullet in the neurologic specialty exam. In fact, it isn't expressly noted in any of the 1997 physical examinations. Instead, look to the "Test coordination" bullet included in both the neurologic and musculoskeletal physical examinations.

It is important to understand the various medical terms that providers use in their documentation. Dysmetria is defined as "an inability or impaired ability to accurately control the range of movement in muscular acts."

Dysdiadochokinesia means "an inability to perform rapidly alternating movements, such as rhythmically tapping the fingers on the knee."

Dysmetria results in overshooting or undershooting of a target while attempting to reach an object and is often tested by asking the patient to extend her index finger and touch her nose, and then touch the neurologist's outstretched finger with the same finger. The patient is asked to go back and forth between touching her nose and the physician's finger. Once this is done correctly a few times at a moderate cadence, the patient is asked to continue with her eyes closed. Normally this movement remains accurate when the eyes are closed. The "Test coordination" bullet includes finger/nose testing as an example.

In testing for dysdiadochokinesia, your neurologist will likely ask the patient to place her hands on her thighs and then rapidly turn her hands over and lift them off her thighs. Once the patient understands this movement, the neurologist will have the patient repeat it rapidly for 10 seconds. Normally, this is possible without difficulty. This is considered a rapidly alternating movement and also included as an example in the "Test coordination" bullet.

The cerebellum provides an important feedback loop for coordination of muscle activity by integrating the functions of the various parts of the brain and the spinal cord. As such, there isn't a single exam that can be performed to test the cerebellar function; rather the neurologist is likely to perform many of the examples listed in the "Test coordination" bullet.