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1997 Guidelines Neurology Exam


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Using the 1997 documentation guidelines, can a Neurology MD satisfy the musculoskeletal bullet requirement for examination of gait and station with the following statement “gait was not assessed because it was medically unsafe to do so”?

One of the neurologist I code for feels it's inappropriate to evaluate the gait in a patient with an acute stroke.

Clarification of this issue is greatly appreciated.

Milwaukee WI
Best answers
I would give credit for this

I would tend to give credit, just as I would if the physician was unable to examine gait/station due to paraplegia or amputation. The physician didn't ignore this part of the exam, but explained why s/he was unable to perform it.

F Tessa Bartels, CPC, CPC-E/M