I have asked that my surgeons dictate... "cranial nerves II-XII normal and intact"
If there is an abnormality, then they dictate something like this..."cranial nerves II-XII normal and intact with the exception of cranial VIII; hard of hearing"
-Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.
-Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
-A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).
I would check with your local Medicare carrier for their policy.
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