CASE.EDU:    HOME | DIRECTORIES | SEARCH

Department of Neurology

 
Neurology:  Content and Documentation Requirements

CPT Code 99214: Level 4

Moderate Complexity Established Patient

For a moderate complexity established patient, one must document two of the three:
 

detailed history

detailed examination

moderate 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 moderate level of medical decision making, and 2) either a detailed history OR a detailed examination.  Considering the requirements, the detailed history is usually more straightforward.


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 an INTERVAL history of one of the three areas:

- Past medical history
-
Family history
- Social History

NOTE: 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.

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 an INTERVAL ROS of 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".


Detailed Neurologic Examination
 

Elements of the neurologic examination are identified by bullets (●). For a detailed neurologic exam, at least twelve 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