E/M documentation guidelines do not take into account the special circumstances associated with performing neurology exams on children. In 1997, CMS unveiled new guidelines that allowed for an extensive, single-system evaluation in place of the multisystem examination required by the previous (1995) guidelines. Although advantageous in most circumstances, the 1997 guidelines contained requirements (e.g., memory and language tests) that could not be met for younger patients. In spite of this, however, pediatric neurologists may still report their services at an appropriate level by substituting the listed elements of the single-system evaluation for other, relevant exam criteria.
1997 Guidelines Allow for Substitution
Neurological exams are reported using the appropriate new or established patient E/M service code (99201-99205 or 99211-99215). But among the elements, or "bullet points," listed in the 1997 E/M documentation guidelines for a neurological examination are several items that cannot reasonably be performed on younger children and infants, says Bruce H. Cohen, MD, chief of pediatric neurology at Cleveland Clinic Foundation in Cleveland, including examination of gait and station, orientation to time, place and person, fund of knowledge (e.g., awareness of current and past events) and language and naming skills. Because of this, the neurologist who performs such an examination on an infant or young child will find it difficult to document the required number of elements to report anything beyond a low-level (i.e., problem-focused or extended problem-focused) exam and, thus, be unable to report an E/M service code that accurately reflects the work expended.
Note: The 1997 (and 1995) Documentation Guidelines for E/M services, including the requirements for a single-system neurological exam, may be viewed as a .pdf or WordPerfect file by visiting the CMS Web site at:
www.hcfa. gov/medlearn/emdoc.htm.
Fortunately, CMS recognizes this shortcoming and allows physicians to substitute specifically bulleted items for other, case-appropriate exam criteria. In describing the documentation of E/M services, the 1997 guidelines explain that the requirements "reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area."
The guidelines also specifically note that "As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate."
Therefore, when you provide [...]
