| |
|
NEUROLOGIC HISTORY AND
EXAMINATION
Summary:
Content and Documentation Requirements |
Depending on the E/M code selected [based on the level
of medical decision making (MDM)], specific documentation requirements are set for
the history and examination. Please remember that
for new patients,
one must document the history, examination and medical
decision making. However,
for follow-up patients, only 2
of 3 are required. Thus, since the MDM is always
documented, either the history OR examination need to be
documented.
|
Documentation Requirements for
Different Levels of History
|
Level of History |
HPI |
PFSH |
ROS |
| Comprehensive |
Extended (≥4) |
Complete
(new=3, Established=2) |
Complete (≥10) |
| Detailed |
Extended (≥4) |
Pertinent (1) |
Extended (2-9) |
|
Expanded Problem Focused |
Brief (1-3) |
Not required |
Problem
specific (1) |
|
Problem Focused |
Brief (1-3) |
Not required |
Not required |
|
HISTORY
Below are listed all the elements in a history. See
the table above for how many elements must be documented
for what level of history.
|
Chief Complaint |
●
Document the
Chief Complaint |
|
History of Present
Illness |
● Document:
-Location
-
Quality
- Severity
- Duration
-
Timing
- Context
-
Modifying factors
- Associated signs and symptoms |
|
Past Medical,
Social and Family History |
●
Document:
- Past
medical history
-
Family history
-
Social History
NOTE: PFSH may be recorded by
ancillary staff or on a form completed by the patient. To document that the
physician reviewed the information, there must be a notation confirming the
information recorded by others.
NOTE: For established patient
visits, PFSH from an earlier encounter does not need to be re-recorded if the
physician reviewed and updated the previous information. The review and update
may be documented by describing any new PFSH information or noting there has
been no change in the information.
|
|
ROS |
●
Document:
- Constitutional
- Eyes
- Ears, Nose, Mouth, Throat
- Cardiac / Vascular
- Respiratory
- GI
- GU
- Integumentary
- Musculoskeletal
- Neurologic
- Psychiatric
- Endocrine
- Hematologic
- Allergies / Immunologic
NOTE:
Permissible to document some systems with a statement "all others negative".
NOTE: ROS may be recorded
by ancillary staff or on a form completed by the patient. To document that the
physician reviewed the information, there must be a notation confirming the
information recorded by others.
NOTE: For established patient visits, ROS from
an earlier encounter does not need to be re-recorded if the physician reviewed
and updated the previous information. The review and update may be documented by
describing any new ROS information or noting there has been no change in the
information. |
|
|
|
EXAMINATION
CMS allows either documentation of a general
multi-system examination or a complete single organ
examination. In the case of
neurology, one would almost always do the single organ
examination as opposed to a multi-system examination.
Elements of the examination are identified by bullets (●). Depending on the E/M code selected (based on the level
of MDM), specific documentation requirements are set for
the examination. Depending on
the level of the exam, different number of bullets must
be documented. In the case of the highest level
(comprehensive), all items marked by a bullet must be
documented. See the table below for specific
documentation requirements for different levels of exam. |
Documentation Requirements for
Different Levels of Exam
|
Level of Exam |
Perform and Document |
| Comprehensive |
Perform
all elements identified by a bullet |
| Detailed |
At least
twelve elements identified by a bullet |
| Expanded Problem Focused |
At least
six elements identified by a bullet |
| Problem Focused |
One to five elements identified by a bullet |
|
NEUROLOGY
SINGLE ORGAN SYSTEM EXAMINATION
(1997 Guidelines)
|
Constitutional |
● Measurement of
any three of the following seven
vital signs:
-Sitting or standing blood
pressure
- Supine blood pressure
-
Pulse rate and regularity
-
Respiration
-
Temperature
-
Height
-
Weight
●
General appearance of patient
|
|
Eyes |
●
Ophthalmoscopic examination of optic discs and posterior segments |
|
Cardiovascular |
●
Document
any one of the following three:
-
Examination of carotid arteries
-
Auscultation
of heart with notation of abnormal sounds and murmurs
-
Examination of
peripheral vascular system by observation and palpation
|
|
Musculoskeletal |
●
Examination of
gait and station
Assessment of motor function including:
● Muscle
strength in upper and lower extremities
● Muscle tone in upper and lower extremities with notation of any atrophy or
abnormal movements
|
|
Neurological |
Evaluation of higher integrative functions including:
● Orientation
to time, place and person
● Recent and remote memory
● Attention span and concentration
● Language
● Fund of knowledge
Test the following cranial nerves:
● 2nd cranial
nerve
● 3rd, 4th and 6th cranial nerves
● 5th cranial nerve
● 7th cranial nerve
● 8th cranial nerve
● 9th cranial nerve
● 11th cranial nerve
● 12th cranial nerve
●
Examination of
sensation
●
Examination of
deep tendon reflexes in upper and lower extremities with notation of
pathological reflexes
●
Test
coordination
|
|
|
|
