Auditing Neurologic Exams: Tips for Success

As an auditor, you may be asked to audit encounters that occur in various multi-specialties. It can be difficult to remember the ins and outs of each specialty, especially if you do not consistently work in a particular specialty. Neurology is one of those specialties that can appear daunting due to specified terminology, particularly when it comes to reflex testing. Within this tip, we will review the terminology you will come across during a neurologic exam (and perhaps in other specialties such as orthopedics) to provide a better understanding and help you succeed in your audit.

Neurologic Reflex Testing

The purpose of reflex testing is to assess the function of the patient's motor and sensory abilities. While it is a simple assessment, the findings give the provider insights into how the nervous system is performing. When the reflex strike is performed with the reflex hammer, the strike occurs to the tendon located at a joint. Impulses within the tendon are sent to the spinal cord and then across a synapse, and then transmitted to the targeted muscle for contraction, causing movement.

Another neurologic exam is referred to as the Babinski sign. The Babinski sign observes how the big toe responds to stimulation at the sole of the foot. The clinician performing the test typically applies pressure beginning at the back of the heel and then moves toward the base of the toes. If the big toe responds by moving up toward the top of the foot, that indicates a positive reflex and could indicate a problem in the central nervous system in older children or adults. Neurologically, newborns and young children are not fully developed and therefore a Babinski sign will normally show. Babinski reflexes are also commonly referred to as plantar response.

Coordination Testing

During a neurologic exam, a provider may also perform coordination tests on their patients. This is done to attempt to rule our dysfunction in the cerebellum, the portion of the brain that is responsible for balance. Several common types of coordination testing include: finger to nose tests (asking the patient to place their finger in a specified location near the nose as instructed by the physician), Finger or hand movement testing, and heel to shin testing (directing the patient to place the heel of one foot up and down along the shin of the opposite leg).

Gait Testing

Gait testing is another technique used by provider to access the neurologic system or sometimes even the musculoskeletal system to help identify any underlying motor, sensory, visual or vestibular issues that may be occurring in the patient. The physician is observing not only the patient's walking ability and balance, but also the patient's ability to get out of a chair, stand on his/her own, etc. On occasion, you may encounter one of the following gait disorders during your audit:

• Ataxic gait - unbalanced, uncoordinated gait which can be an indication of diseases affecting the brain such as stroke, tumor, multiple sclerosis and more)

• Hemiplegic gait- describes patients walking with their arm flexed close to their body, an indicator of motor weakness

• Neuropathic gait - noted when the patient raises his/her leg and striking it firmly on the ground, which can indicate metabolic disorders or other deficiencies involving the sensory system

• Antalgic (limping) gait- placing weight on the affected leg for the least amount of time. This occurs due to injury or degenerative disease involving the hip, knee or leg.

As auditors, E&M services are essentially the same as they all require history, exam, and medical decision making (MDM), but the variations between the specialties can make a difference in the presentation of the complexity of care of the patient. The provider must still paint the portrait of the patient, but having a better understanding as an auditor of the type of canvas and oils the provider is using to create that portrait will make you a better connoisseur of their art.

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