Neuro examination

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Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Sep 27, 2018 4:12 pm

How would you score this:
Vitals: (completed with three areas covered in note)
General: Hair, skin, nails, extremities and general appearance.
HEENT: Fundoscopic examination, cervical lymph glands, thyroid and oropharynx.
Cardiovascular: Auscultation of carotid arteries and the heart.

A careful, comprehensive neurological examination was carried out as documented in the addendum seen below and was found to be normal unless otherwise documented below.

The patient has several days appear growth, ecchymoses in the forearms, has an antalgic gait. We did not having tandem were heel walk. Would not having toe-walk. He has got intact vibration at the knees but intact pinprick. Reflexes are absent in the lower extremities at the ankles and intact at the knees great on the right than left although upper extremity reflexes are symmetric. He cannot name the index finger. His fundi are benign. He recalls 3 of 3 objects. He tends to sit quietly lives wife to a lot of the talking although he is a very keen observer and states that he does not care for the new computerized medicine with the doctor seems not to be pain attention to the patient.

(spelling as is dictated).

This is a neurology consult and doctor wants to bill for a complete exam.
Posts: 7
Joined: Thu Mar 08, 2018 12:14 pm
Location: Redding, California

Thu Sep 27, 2018 5:56 pm

Does not meet 1997 Guidelines at all (just with the missing test to the cranial nerves) and at best Detailed for 1995 guidelines. My opinion. :)
Alexis Riley, MA, RHIA, CHPS, CPC
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