caveat -find it documented

alices

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when using the caveat for the E/M (emergency room) is it only for the history or does it pertain to Exam as well? and if so can you tell me where I can find it documented?..thank you, any and all help would really be appreciated..alice
 

Mojo

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when using the caveat for the E/M (emergency room) is it only for the history or does it pertain to Exam as well? and if so can you tell me where I can find it documented?..thank you, any and all help would really be appreciated..alice
From the ACEP website:
The Level 5 Caveat
The definition of 99285 includes the concept that the History, Physical Exam, and Medical Decision Making requirements must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". Most Medicare carriers require a description of the patient's urgent condition and the physician's thought process. So make sure to document why the severity of your patient's illness precludes performing a full History or Exam.

AAPC's article can be found here: http://news.aapc.com/index.php/2010/05/good-faith-effort-warrants-level-5-em/
 

sjb280

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When I look for a caveat for ER E/M's, the place I will find it the most is for the review of systems, which can be used for the entire history. I have seen a few for the exam, but not many. It still is up to what the physician documents about the ability to get the full amount needed/severity of illness of the patient. I code for Emergency Room physicians, and I've seen alot of poor tries for caveats, so just make sure what they do write includes the reason why they couldn't get the history, or that they did cover everything. For example, I couldn't get the history due to patients dementia...or a complete review of systems was done and all are negative, or some variation. I'm sure there are many guidelines on that, that is just an example of what I use.
 
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