Good Morning All,
I have several neurologists that are using the 97 guidelines for single organ system. They always document constitutional, cardio, eyes, musculo, orientation,
and examination of sensation, deep tendon, and tested coordination. My challenge is documentation for cranial nerves 2 through 12. This portion is documented in various
ways. One provider was told it is acceptable to document cranial nerves 2 through 12 are intact. Another example would be cranial nerves 2 through 12 are negative
for abnormalities. Sometimes they will put cranial nerves 5 through 9 deferred. Which I was always under the impression that deferred was unacceptable. That they
would have to document why they are unable to examine that nerve or area?
My question is, are they allowed to document these shortcuts and receive credit for a comprehensive exam? Also, is there documentation stating that they have to
test and document each nerve? I do not want to instruct them to start using these shortcuts, and have to retract my education. A lot of neuro cases involve the patient
being sedated, or in a coma. Physical examinations cannot be caveated, but is there a way for them to document a comprehensive visit for these patients? The highest
level of exam that I am able to pull for them is detailed. As they typically state patient is intubated or in coma, deferred portion of exam.
Has anyone else dealt with this, or have some suggestions on how to educate the providers on this portion of the exam?
Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.
1 post • Page 1 of 1