Exam Question

dballard2004

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I am auditing an orthopaedic/sports medicine chart and the provider has documented under the exam that the patient is "neurologically intact distally." My question is where do you apply the bullets for this statement? Thanks.
 

bmontemayor

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It means the nerves are in tact, I would put it in cranial nerves bullet. I did a CPMA class where this was an example. Hope this helps.
 
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NOT cranial nerves

But these are NOT cranial nerves!

I am assuming that you are using 1997 guidelines - perhaps even the Musculoskeletal Specialty Exam ...
I wonder whether he is examining "sensation"? Definitely to query provider and give some education on what constitutes the comprehensive exam in 1997 guidelines.

In 1995 guidelines you would count this as neurologic system.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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