Wiki Cranial Nerve Documentation

[rogers]

Can anyone who's coding neurology tell me if the statement "cranial nerves intact" is enough documentation to support a level 5 e/m when all other elements are met, or does the documentation need to expand on each cranial nerve 2-12?
Thanks in advance

 

[penguins11]

No, it is not enough to say cranial nerves intact, you have to expand on each nerve.

 

[FTessaBartels]

1995 vs 1997 guidelines

The guidelines are more vague with 1995, so would definitely count for neurological system.

I would argue that the statement would satisfy 1997 guidelines as well. The bullet states "Test cranial nerves with notation of any deficits."
While it is preferable (and we train our physicians to do so) to document "cranial nerves 2-12 intact," the bullet doesn't specify how many of the cranial nerves have to be commented upon.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[penguins11]

At the last Medicare seminar I attended, they said that it is not enough to say cranial nerves all intact, you do have to specify which nerves. They will not give credit if they audit you if this is all your physician says for the 97 guidelines.