Neurosurgery Coding Alert

Question: Our neurosurgeon 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. Dysmetria is defined as "an inability or impaired ability to accurately control the range of movement in muscular acts." It results in overshooting or undershooting a target while attempting to reach an object. Your physician might test for dysmetria by asking the patient to extend her index finger and [...]