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Neuro Exam components

  1. #1
    Default Neuro Exam components
    Medical Coding Books
    Does anyone know if it is acceptable for a physician to state "cranial nerves II-XII intact" and get credit for testing the cranial nerves on the Neuro exam. My feeling on this is that they need to state each nerve tested, however, my physicians think this is acceptable. I'd like to check with some other coders for your input.

  2. #2
    North Carolina
    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.

  3. Wink "cranial nerves II-XII normal and intact"
    I agree with Rebecca, all the Physician's I have coded for make their note "cranial nerves II-XII normal and intact". I even had one show me how he does that assessment and after that I agree he really does need credit for that.
    Last edited by dtovar; 03-27-2009 at 04:05 PM.

  4. #4
    Milwaukee WI
    Default 1997 General exam or Neuro specialty exam?
    I'd like some clarification, please. Are you asking whether the statement is acceptable for use with the 1997 general physical exam? Or are you asking whether this is acceptable for the 1997 Neurology Specialty exam?

    F Tessa Bartels, CPC, CEMC

  5. #5
    for the 1997 neurology exam.

  6. #6
    Milwaukee WI
    Default Neuro Specialty Exam
    No, I wouldn't count this for the Neurological specialty exam. The guidelines for this area read:

    2d cranial nerve (e.g. visual acuity, visual fields, fundi)
    3rd, 4th and 6th CN (e.g. pupils, eye movements)
    5th CN (facial sesation, corneal reflexes)
    7th CN (facial symmetry, strength)
    8th CN (hearing w/ tuning fork, whispered voice and/or finger rub)
    9th CN (spontaneous or reflex palate movement)
    11th CN (shoulder shrug strength)
    12th CN (tongue protrusion)

    So, I'd want to see an explanation for each of these nerves.

    If you were using the 1997 General Multi-System exam, then YES, I'd count the phrase "Cranial Nerves II-XII intact) as one neuro bullet.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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