Neurology & Pain Management Coding Alert

Question: We have a new neurologist in our department. In her examination documentation she writes, "On neurological exam, higher integrative functions were normal." Based on the 1997 neurological examination guidelines, should I credit for all functions? If not, what should I credit?

New York Subscriber

Answer: The term "higher integrative function" is also known as cognitive function testing. This often includes orientation to time, place and person, recent and remote memory, attention span and concentration, language and fund of knowledge.

However, the best option is to request that the neurologist outline the specific functions examined so you can establish that all the necessary components were present for reimbursement.

Here's why: When your physician suspects that a patient has a neurologic disorder, she evaluates all of the subject's body systems during the physical examination, with an added focus on the patient's nervous system.

What you need: According to the CMS 1997 Documentation Guidelines for Evaluation and Management Services, the neurologic specialty exam includes the following:

- evaluation of higher integrative functions

- testing cranial nerves II through XII

- test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)

- examination of the patient's deep tendon reflexes testing upper and lower limbs with notation of pathological reflexes (e.g., Babinski)

- examination of sensation (e.g., by touch, pin, vibration or proprioception).

Your neurologist may choose to evaluate some areas more thoroughly than others depending on the type of disorder she suspects for this specific patient.