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Neurology:
Content and Documentation Requirements
CPT Code 99263: High Complexity
Follow-up Inpatient
Consultation |
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This code is only used if you stop
seeing a patient (i.e., sign-off) and are later asked
during the same hospitalization to provide another
consultation. If you follow an inpatient on subsequent
days, those visits are coded as subsequent hospital
visits. For a high complexity follow-up inpatient consultation,
one must document two of the three:
● detailed history
●
detailed examination
●
high 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 high 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.
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Interval History |
●
Document
four or more of
the following:
-Location
-
Quality
- Severity
- Duration
-
Timing
- Context
-
Modifying factors
- Associated signs and symptoms |
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Past Medical,
Social and Family History |
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Not required |
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ROS |
●
Document
two 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". |
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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.
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NEUROLOGY
SINGLE ORGAN SYSTEM EXAMINATION (1997 Guidelines)
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Constitutional |
● Measurement of
any three of the following seven
vital signs:
-
Sitting or standing blood
pressure
- Supine blood pressure
-
Pulse rate and regularity
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Respiration
-
Temperature
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Height
-
Weight
●
General appearance of patient
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Eyes |
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Ophthalmoscopic examination of optic discs and posterior segments |
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Cardiovascular |
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Document
any one of the following three:
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Examination of carotid arteries
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Auscultation of heart with notation of abnormal sounds and murmurs
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Examination of
peripheral vascular system by observation and palpation
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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
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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
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Examination of sensation
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Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes
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Test coordination
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