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Level of neuro exam

  1. #1
    Default Level of neuro exam
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    I can't find any publications that support a comprehensive neuro exam can be met if certain aspects of the 97 bulleted exam are not met due to several different scenarios. Ie the comatosed pt, intubated on a vent or a confused pt who cannot answer certain mental status questions, or a patient who refuses to cooperate for some of the cranial nerve bullets and mental status exam. In the CMS documentation guidelines for history when a patient is unable to answer questions, the documentation should be specific as to why a complete history was unobtainable. Then a comprehensive history can be met. There is no documentation guideline to default to a comp level of exam if the circumstances are documented. The arguement from the provider is the 95 exam would not be applicable since the exam is specifically for neuro.
    I need opinions or resources for the above questions.

  2. #2
    Flower City
    I would write a coding caveat policy for coding a comprehensive exam whether 95 or 97 guidelines when you have unresponsive patients due to critical issues that prevent them from responding. Most Neurology practices use the 1997 guidelines. You can use one or the other but not both.
    Caveat means qualification, stipulation limitation etc... so a coding caveat policy that defines when you code a comprehensive exam in the event of certain medical circumstances where an exam cannot be completed supports your coding practice. Use the policy consistently. Write this policy using the CMS guidance you mention and define medical scenarios that would qualify; have a physician bless the scenarios so it is clinically accurate. Have the physicians in the practice sign off on the policy.
    When the physician documents the visit they must document specifically why the patient's exam...was not completed. Example; patient was agitated due to encephalopathy, unable to obtain full (the part of the exam incomplete) ....etc..
    The Emergency Departments, Trauma Centers can this caveat for coding.
    Psychiatry is another department that this could apply to as well. Hope this is helpful. If you have further questions let me know.
    Marianne Wink, RHIT, CPC, ACS-EM

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