California – Neurology – Lack Of Documentation When Diagnosing Neuropathic Pain, RLS, and Carpal Tunnel Syndrome With Normal Neurological Examination

A 43-year-old male was referred by his primary care physician to a neurologist for multiple medical issues, including obesity, chronic post-operative pain following lumbar spine surgery, major depressive disorder, familial tremor, shoulder pain, excessive daytime sleepiness, congestive heart failure, and peripheral neuropathy.  The patient had been on Norco and was switched to Tramadol. The dose of Tramadol was 100 mg 4 times a day. Other medications were trazodone 100 mg h.s., zolpidem 10 mg h.s., HCTZ 25 mg, Lasix 40 mg, Flomax 0.5 mg, and topiramate 100 mg twice daily.

On 3/27/2014, the neurologist saw the patient for an office visit.  The patient complained of symptoms of foot pain, burning, and restless leg syndrome (RLS) symptoms.  The neurologist diagnosed neuropathic pain, RLS, obesity, carpal tunnel syndrome, low back pain, and tremor.  She planned to do B12 and ferritin levels, and she recommended an EMG/NCV of both upper and lower extremities.  The neurologist noted a normal neurological examination. Despite the normal neurological examination, the neurologist failed to keep adequate documentation to establish her multiple diagnoses.  She coded the visit as a level 5 new patient evaluation. The neurologist failed to document her 14-point review of systems and other required examinations to substantiate level 5 billing.

During a subsequent interview with the Medical Board, the neurologist initially stated that she had no recollection of the patient.  Her medical report timed the office visit at 9:15, and the encounter ended at 11:11 a.m., approximately 2 hours. She stated that she spent 40 minutes with him.  She could not account for the other time. She stated that “the rest was not me” and that she did not know what the time was “in between.” The patient claimed that she asked him only to stand and to try to stand on his heels and to squeeze her fingers.  When asked why she ordered the EMG, she answered, “For neuropathy versus radiculopathy versus carpal tunnel syndrome could have CDIP.” She did not know what a Controlled Substance Utilization Review and Evaluation System (CURES) report was.

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to keep accurate, timely, complete medical records to support her diagnoses, coded and billed for level 5 services not substantiated in her records, and was not aware of CURES reports and did not utilize it in her practice.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Extremity Pain, Back Pain, Joint Pain, Psychiatric Symptoms

Diagnosis: Neurological Disease

Medical Error: Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

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