Bullets

[joslynh1]

I work in psych and if a patient is combative, psychotic or want respond to the review of systems or the exam and the attending documents this do you still give them the bullet point as though he documented a finding?

[tmerickson]

If the provider documents the exact situation where the patient was unable or would not cooperate with the exam, then yes, you can count those bullets. The documentation has to be very clear, and obvious to an auditor the reasons why it was defered or difficult to collect information. This should not become a common thing for your provider though. Situations like these are few and far between. We want to be paid for our time, and if only a few elements in the ROS or Exam was captured, then that is all that should be reimbursed.

[FTessaBartels]

Be sure you check with your carrier/payer. A few do NOT allow you to claim credit for a full history unless you actually take a full history (including ROS and PFSH).

MOST will allow credit when there is a specified reason why the ROS and/or PFSH could not be obtained (For Example: unconscious patient and no family present)

Hope that helps.

F Tessa Bartels, CPC, CEMC