graciejean
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I can't find any publications that support a comprehensive neuro exam can be met if certain aspects of the 97 bulleted exam are not met due to several different scenarios. Ie the comatosed pt, intubated on a vent or a confused pt who cannot answer certain mental status questions, or a patient who refuses to cooperate for some of the cranial nerve bullets and mental status exam. In the CMS documentation guidelines for history when a patient is unable to answer questions, the documentation should be specific as to why a complete history was unobtainable. Then a comprehensive history can be met. There is no documentation guideline to default to a comp level of exam if the circumstances are documented. The arguement from the provider is the 95 exam would not be applicable since the exam is specifically for neuro.
I need opinions or resources for the above questions.
I need opinions or resources for the above questions.