ED Coding and Reimbursement Alert

Question: An apparently homeless patient presents to the ED via ambulance unresponsive with a suspected brain aneurysm. The patient, who had no identification on his person, was found by a homeless man who accompanied the patient to the ED in the ambulance. The man said that he "knew the guy a little bit; he had been complaining about his neck and bad headaches lately." The man could not, however, provide more than the patient's first name. Therefore, the physician had almost no history information; she did, however, provide a comprehensive examination and perform high-complexity medical decision making (MDM) before admitting the patient for further neurological services. How do I gauge the level of history for E/M coding purposes?Answer: This could be an instance in which the ED caveat is appropriate, which allows for gathering history and physical exam within the constraints imposed by the patient's condition if the patient's care [...]