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Posts: 1
Reply with quote  #1 
I'd like some clarification for this pls. 

On physical exam the Dr. dictates neurological exam is completely normal, It this acceptable notation or documentation to use as detailed exam under 1997 guidelines?

2nd question
Dr. dictate Cranial nerve II-XII is intact. Is this counted as 8bullets unter neurological exam?

Posts: 2
Reply with quote  #2 
if you were doing a multi-organ sytem exmam according CMS guidelines,

 "DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)".

However, if you were doing an organ specific exam (in this case, Neurological) then the guidelines require the following:

Content and Documentation Requirements

Level of Exam

Perform and Document:

Problem Focused

One to five elements identified by a bullet.

Expanded Problem Focused

At least six elements identified by a bullet.


At least twelve elements identified by a bullet.


Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.



Evaluation of higher integrative functions including:

Orientation to time, place and person

Recent and remote memory

Attention span and concentration

Language (eg, naming objects, repeating phrases, spontaneous speech)

Fund of knowledge (eg, awareness of current events, past history,


Test the following cranial nerves:

2nd cranial nerve (eg, visual acuity, visual fields, fundi)

3rd, 4th and 6th cranial nerves (eg, pupils, eye movements)

5th cranial nerve (eg, facial sensation, corneal reflexes)

7th cranial nerve (eg, facial symmetry, strength)

8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or

finger rub)

9th cranial nerve (eg, spontaneous or reflex palate movement)

11th cranial nerve (eg, shoulder shrug strength)

12th cranial nerve (eg, tongue protrusion)

Examination of sensation (eg, by touch, pin, vibration, proprioception)

Examination of deep tendon reflexes in upper and lower extremities with

notation of pathological reflexes (eg, Babinski)

Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating

movements in the upper and lower extremities, evaluation of fine motor

coordination in young children)


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