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Department of Neurology
 
Neurology:  Content and Documentation Requirements

CPT Code 99204: Level 4

Moderate Complexity New Patient
For a moderate complexity new patient, one must document all three:
 

● comprehensive history

● comprehensive examination

● moderate level of medical decision making

Detailed History
 

Below are listed all the elements in a detailed history that must be documented.

Chief Complaint ● Document the Chief Complaint
History of Present Illness ● Document four or more of the following:

-Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying factors
- Associated signs and symptoms
Past Medical, Social and Family History ● Document all three areas:

- 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.
ROS ● Document ten or more of the following:

- 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".

Detailed Neurologic Examination
 

Elements of the neurologic examination are identified by bullets (●). For a detailed neurologic exam, all elements identified by a bullet must be documented.
 

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