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Department of Neurology
 
Neurology:  Content and Documentation Requirements
 

CPT Code 99231: Low Complexity Subsequent Hospital Care
This code is generally used for stable patients with no change or no issues. For a low complexity subsequent hospital, one must document two of the three:
 

● problem focused history

● problem focused examination

● straightforward OR 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 straightforward or low level of medical decision making, and 2) either a problem focused history OR a problem focused examination.  Considering the requirements, the problem focused history is usually more straightforward.

Problem Focused History
 

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

Interval History ● 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 Not Required

Problem Focused Neurologic Examination
 

Elements of the neurologic examination are identified by bullets (●). For a problem focused neurologic exam, at least one element 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