Documentation of E/M services for Neurology (Don't Forget the Cardiology Element)

June 13th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   CPT® Coding   Neurology|Neurosurgery  

According to Neurology Clinical Practice and NBIC, the neurologic exam is commonly lacking in documentation due to the extensive requirements needed to capture the appropriate revenue.

With the lack of precise documentation, it results in a lower level of E/M than that which is more appropriate, which can cost a physician a lot of lost revenue. The E/M  Evaluation and Management codes are based on medical complexity or time spent on care.  The 1997 guidelines were revised to include a new general multi-system examination and several single organ system examinations, one of which is neurology.  

The clinical neurology exam has 25 elements with 22 neurologic exam findings. This also includes 3 elements of the cardiovascular examination. If any part is omitted or there is not one cardiology element reported, then the comprehensive examination cannot be reported and you must drop it to the next level down. For the Cardiology element to be complete you only need 1 element to report a comprehensive exam using 99222 or 99223, however, you can report 1-3 elements.

97 Guidelines for Neurology E/M Exam

Neurological 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, vocabulary)

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)


  • Examination of carotid arteries (eg, pulse amplitude, bruits)
  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)


  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be
    measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)


  • Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association