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Department of Neurology
 
Neurology:  Content and Documentation Requirements

CPT Code 99213: Level 3

Low Complexity Established Patient
For a low complexity established patient, one must document two of the three:
 

● expanded problem focused history

● expanded problem focused examination

● low level of medical decision making

Since the E/M code is best determined by the medical decision making, essentially this means that you must document 1) a low level of medical decision making, and 2) either a expanded problem focused history OR a expanded problem focused examination.  Considering the requirements, the expanded problem focused history is usually more straightforward.

Expanded Problem Focused History
 

Below are listed all the elements in an expanded problem focused history that must be documented.

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

-Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying factors
- Associated signs and symptoms
Past Medical, Social and Family History Not Required
ROS ● Document one 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: 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.

NOTE:  Permissible to document some systems with a statement "all others negative".

Expanded Problem Focused Neurologic Examination
 

Elements of the neurologic examination are identified by bullets (●). For an expanded problem focused neurologic exam, at least six 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