Neurology & Pain Management Coding Alert

Question: I need clarification regarding the 1997 E/M guidelines. When our neurologist documents the cranial nerves during an exam, can he write, "cranial nerves II through XII were intact" and count individual bullet points for that (if he's using the neurologic exam versus the general exam)? Or do we not get credit because the documentation should be more specific?

Nevada Subscriber

Answer: The more thoroughly your physician documents the procedure, the more accurately you can code the procedure.

All cranial nerves should be listed separately, which means your physician must specifically document each nerve tested before reporting a bullet for each nerve.

Education opportunity: Ask your physician to let you sit in on a patient exam and see what he routinely does. That might encourage him to better document his work. Then ask afterward which part of the exam tested each nerve, so you understand the procedure better from a coding perspective.