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1997 guidelines element

S

sullivak

Guru
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124
Location
Santee, CA
Does this statement count anywhere in 1997 guidelines?

NEUROLOGIC: No gross focal motor neurologic deficit

I'm thinking no, but I've seen some count it as Cranial Nerve test??? :eek:
 
Thanks, Simone. One of our physicians said that it's not really cranial nerves but more of a neurological test for weakness in extremities. This is what had me concerned about counting this verbiage as a Cranial Nerve test element.
If auditors are giving credit though, it seems more legit to me now.
Thanks for your feedback!
Kim
 
Does anyone else have ideas about this? I'm getting push back on the issue. I wish I could find some official documentation on the matter.
Thanks,
Kim
 
Your provider may be right, I asked two neurosurgeons here what part of the body do they assess to check for focal deficits and they both stated that they check for eyelid dropping, speech impediments, loss of muscle control, loss of sensation and loss of motor fine skills. So it appears that exam elements can be picked up in Neuro and MSK body systems depending on how the provider documents what he is checking. Hope this helps. I would love to hear other coding perspectives on this too Good question!
 
I see this all the time from my providers, and I am not sure if I can count it using 97 guidelines, and if so, under which system?

Neurologic Exam: nonfocal

I don't feel like that tells me much of anything and shouldn't be counted.

Thanks,
Arrana:confused:
 
My understanding of the 1997 guidelines is that the elements listed are what need to be documented. In the 1997 General Multi System Exam under neurologic the bullets are 1) Test cranial nerves with notation of any deficiits, 2) Examination of deep tendon reflexes with notation of pathologic reflexes (eg Babinski), 3) Examination of sensation (eg by touch, pin, vibartion, proprioception).

The reason the 97 guidelines were established was because the 95 were considered to vague. When I look for documentation I look for the points listed in the guidelines, if they're not there I don't give credit. In your example I think that "nonfocal" is too vague. What part of the neurologic exam did the provider actually do?

I know people look for different things which is what makes auditing difficult (and interesting) so this is just my opinion.
 
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