Comprehesive history - patient is intubated

Love Coding!

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Hello,

Does anyone know if the patient is intubated and a history cannot be obtained and the physician list why, by default would this be considered a comprehensive history? (extended HPI, 10+ systems reviewed and all three areas of the PFSH). If this helps my physicians are in Nevada (Palmetto GBA J1) and Arizona (Noridian). I have checked both websites and did not give me any insight about the HPI.

Thank you,
 
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mcandia

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Comprehensive history - patient is intubated

Defaulting to a comprehensive history pertains to ROS and PFSH components only and does not include the HPI.

A history / HPI has to be obtained / documented whether by review of records, family member etc.

As long as the detail with a statement such as "unable to obtain patient's ROS & PFSH due to patient intubated, unresponsive etc. then this would qualify as comprehensive for these areas.

Maria
 

aimie

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History

I am taking the E/M online training. What do u mean by default. Can u explain little further. I am trying to keep my skills fresh while I am looking for work.

Thank You

Aimie
 

mcandia

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Comprehensive history - patient is intubated

"By default" just means that the scoring / obtainment of "comprehensive" was achieved in lieu of obtaining these items from the patient for a stated reason i.e., patient intubated, unresponsive etc.

Maria CPC, CPC-H, CPCO, CPMA, CEMC
 
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