Cardiology Coding Alert

Apply E/M Rules to Advantage When Patient Hx Isn't Possible

You can get credit for the attempt if you follow this documentation tip.

Your cardiologist may sometimes perform E/M services on patients who are unable to respond to questions and can't offer a history. What will it mean for your E/M level? Here's a hint from the authorities.

If You Can't Get Hx, Be Sure You Get Reason

When patients present as unresponsive, mentally unstable, or even substance impaired -- especially if there's no accompanying family or caregiver -- the cardiologist may not be able to take a history, says Dorothy  Steed, CPC-H, CHCC, CPUM, CPUR, RCC, ACS-OP, CCS-P, RMC, CPC-EMS, CPC-FP, PCS, FCS, CPHM, CPAR,an independent consultant in Atlanta.

When the patient is unable to give a history due to dementia or altered mental status, for example, the physician should clearly indicate why she couldn't obtain a reliable history, Steed says.

Support: The 1995 E/M guidelines instruct that "if the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, coding and compliance manager for UPMC-Surgery/Anesthesia in Pittsburgh.

You will find the same instruction in the 1997 guidelines. (You can download the 1995 and 1997 guidelines at

Tip: "A common condition preventing the procurement of a comprehensive history for cardiologists is the fact that patients are occasionally intubated and/or sedated.The statement 'I cannot obtain a comprehensive history because the patient is intubated'" is appropriate, says Jim Collins, CCC, CPC, president of CardiologyCoder.Com in Saratoga Springs, N.Y.

See If Choosing Comprehensive History Is OK

The question remains how the inability to get a history affects your E/M level, though.

Good news: "The practice is that if you are unable to obtain any piece of the history, as long as you illustrated what you tried to get and why you were unable to elicit that information, you get the appropriate credit for it,"Berman says.

Experts contend that means if the cardiologist documented attempting to obtain a history and why he was unable to do so, you may consider this a comprehensive history in choosing your E/M level.

Helpful: You may find written support from your payer on this approach. For example, J14 MAC NHIC has an E/M audit tool that states, "Allow a comprehensive history if the physician is unable to obtain a history from the patient or other source. The record should describe the patient's condition or circumstance that precludes obtaining history" (

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