Neurology Exam

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Joined: Sat Aug 08, 2015 4:32 pm

Tue Oct 24, 2017 9:53 pm

Is there a standard documentation requirement for a Neurological exam, specific to MMSE and cranial nerves? Another words can you document 30/30 and circle MMSE and CN 2-12 Nl with no other documentation to support it? The MMSE is included and not available for audit.

Any help on where I can go for a reference would be greatly appreciated.
Ann :?
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Joined: Mon Apr 09, 2012 1:54 pm

Wed Nov 08, 2017 10:38 am

Well, you are now relying on the auditor and the reader of the note to be able to interpret (which we are NOT supposed to interpret or assume) the exam. While we can surmise that alert and oriented represents a patient that is pretty well normal neurologically, this type of exam is not that straightforward in the findings.

If I were auditing the files, I would tend to allow it for precision purposes, but educate the provider on a more successful documentation approach. If the provider argues, well technically he is right- a physician should not have to document to an auditor or coder, but the realty of the healthcare industry is that currently they do. But, they don’t have to document in this way, provided they understand that there may not be the same level of interpretation.

Your question was answered by Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
Posts: 7
Joined: Sat Aug 08, 2015 4:32 pm

Thu Nov 09, 2017 11:25 pm

Thank you Shannon for your reply.
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