Neurology & Pain Management Coding Alert

You Be the Coder:

Documenting a Nonresponsive Patient

Question: One of our patients is nonresponsive and unable to answer questions. The neurological exam includes bullets for fundamentals of knowledge, language, and recent and remote memory. Can we count those as bullets for the exam? Connecticut Subscriber Answer: You should be able to count those bullets, if your physician documents the situation completely. If he documents that the patient cannot respond, the patient's unresponsiveness implies the neurologist's attempt to assess the patient's state. Your physician can document the situation with wording such as "Language, fundamentals of knowledge, recent and remote memory could not be assessed because the patient was comatose or obtunded or delirious."
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