Nuwer M R, Sigsbee B
UCLA Department of Neurology, USA.
Neurology. 1998 Feb;50(2):497-500. doi: 10.1212/wnl.50.2.497.
Medicare recently announced the adoption of minimum documentation criteria for the neurologic examination. These criteria are added to existing standards for the history and medical decision-making. These criteria will be used in compliance audits by Medicare and other payors. Given the current federal initiative to eliminate fraud in the Medicare program, all neurologists need to comply with these standards. These criteria are for documentation only. Neurologic standards of care require a more complex and diverse examination pertinent to the problem(s) under consideration. Further guidance as to the content of a neurologic evaluation is outlined in the article "Practice guidelines: Neurologic evaluation" (Neurology 1990; 40: 871). The level of history and examination required for specific services is defined in the American Medical Association current procedural terminology book. Documentation standards for examination of children are not yet defined.
医疗保险最近宣布采用神经系统检查的最低记录标准。这些标准被添加到现有的病史和医疗决策标准中。这些标准将用于医疗保险和其他付款方的合规审计。鉴于当前联邦政府消除医疗保险计划欺诈行为的倡议，所有神经科医生都需要遵守这些标准。这些标准仅用于记录。神经系统护理标准要求进行更复杂、更具针对性的检查，以解决所考虑的问题。“实践指南：神经系统评估”（《神经病学》1990年；40：871）一文概述了有关神经系统评估内容的进一步指导。美国医学协会现行的程序术语手册中定义了特定服务所需的病史和检查水平。儿童检查的记录标准尚未确定。
