Oncology & Hematology Coding Alert

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. He performed a comprehensive exam and complex (high) medical decision making based on the patient's current condition. Can we give credit for a comprehensive history even though he couldn't obtain a comprehensive ROS (review of systems) due to the patient being mentally confused?

South Carolina Subscriber

Answer: In general, you can give credit only for the level of history that is documented. However, when the documentation meets certain requirements, payers may allow you to count history toward the level of E/M service you bill even if the physician is unable to obtain the history directly from the patient.

What the guidelines say: Both the 1995 and 1997 "Documentation Guidelines for E/M Services" state, "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."

Experts contend that if the physician documented attempting to obtain a history and why he was unable to do so, the common practice is for payers to allow a comprehensive history.

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" (www.medicarenhic.com/providers/articles/E_M_complete.pdf).

Verify that your physician clearly documents the reason the patient is unable to provide a history. For example, the patient may be intubated, unconscious, or suffering from dementia. The physician should also 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 history components (past medical, family, social). Then if the physician performed and documented a comprehensive physical examination and complex medical decision making, you may bill the comprehensive visit according to the guidelines of the specific payer.