1995 guidelines are very vague .. which is why the 1997 guidelines came into being. But then the doctors had collective heart failure at the detailed documentation requirements in 1997, so 1995 was kept in place and people were given the choice of which to use.
My advice is to have a list of bullets that your practice considers necessary for a complete neuro exam. And then to stipulate how many of those bullets are minimally required to be considered "complete single system exam."
So start with the 1997 list ... JUST the NEURO part ... and ask your physician how many of those 16 bullets s/he feels constitutes a complete single system exam.
Assuming the response isn't totally out of line (for example: 3), put that guideline into your compliance plan. And follow it.
Any outside auditor will start by asking for your practice compliance plan/policy/standards. The auditor may not agree with your plan, but if you have it in writing you can at least make your case and show consistency.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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