1997 E&M Documentation Requirements

[Donna C.]

On the 1997 guidelines - If the doctor states "patients neurological exam is normal" does everything under neurological count, including the listing of cranial nerves?
Also, under the Musculoskeletal - does each box checked count as one element: gait & station, muscle strength upper & lower extremities, muscle tone upper & lower extremities?
Thank you.

Donna Cassella

 

[suzanberman]

Unless the details are documented, you cannot give credit for that system.
Depending on the level of examination you want to bill will depend on how many boxes for 1997 need to be checked.

You might consider using the 1995 guidelines. They would give credit for the neuro exam as well as provide for the Musculoskeletal exam as well.

 

[Donna C.]

Thank you!