General Surgery Coding Alert

Question: One of our surgeons admitted a 72-year-old woman as an initial inpatient. He performed a comprehensive physical examination and complex medical decision making based on the patient's current condition, but he couldn't get all of the patient's personal information because she appeared to be mentally confused. Can we count this as a comprehensive history even though the surgeon couldn't obtain a comprehensive review of systems (ROS) due to the patient's mental status?

Nebraska Subscriber

Answer: There is no written rule that you can automatically give credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unobtainable due to patient condition. In general, you can only give credit for the level of history that the surgeon documents. This viewpoint might be payer specific, so check with your local payer.

Tip: In many cases, however, you are allowed to count history toward the level of E/M service you bill even if you are unable to obtain it directly from the patient. You must document that you made an effort to obtain information about the patient from other sources.

Action: The "Documentation Guidelines for E/M Services" states, "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 circumstances which precludes obtaining a history." Accordingly, verify that your surgeon clearly documents the reason the patient is unable to provide a history, and document his efforts to obtain the patient's history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available), and using information from the records to document some of the historical components (past medical, family, social).

Note: In certain cases you can choose not to use history to select your code. If the E/M code you wish to bill requires only two of three E/M components, use the physical examination and medical decision making to determine the level of service. If the comprehensive service takes place in an emergency room, code 99285 (Emergency department visit for the evaluation and management of a patient ...) because the definition of this CPT code includes the exception "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."

Bottom line: If you have indicated that you sought information from all available sources, and your service requires a comprehensive history, and you have performed a comprehensive physical examination and a complex medical decision making, you may bill the comprehensive visit according to the guidelines of the specific payer.