I am having a discussion with another auditor regarding what should be accepted in the Neuro check. When we look at the 1997 General Multi-System Exam we see:
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)
And Psychiatry shows Orientation to time, place and person
However, if we look at Genitourinary exam we see Neuro/Psych and Orientation (e.g. time, place and person) and Mood and affect (which appears to be only Psych).
We are wondering if there is any guidance on this. Another example is sometimes I will see "Neuro: Patient denies dizziness". In my mind this should be reported under HEENT (vestibular). It is not so much about categorizing the documentation as it is making sure that we are thinking about this in the correct way.
To be clear we are typically auditing from a Family Practice perspective (1995 Guidelines) but sometimes from 1997 as well.
Any input is appreciated.
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