Wiki Physical Exam when Patient is Unarousable

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j.berkshire

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When a patient is unarousable, and cranial nerves are documented as "not examined; unarousable" do you count these towards the level of examination using CMS 1997 neurology guidelines?

We have instruction from CMS addressing a ROS that is unobtainable, but I have found no guidance for the same situation with the physical exam.

Thoughts and comments are appreciated and thanks,
 
No, like you said you can get credit for unobtainable elements of the Review of Systems, and even the family history (unobtainable if adopted for example) but you can't do that for the physical exam. I would advise you against using the 1997 guidelines in that instance.

You might consider using the 1995 exam guidelines, or coding the encounter based on time spent counseling the patient's guardian.
 
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