Wiki Critically Ill Patient

[Lassal423]

How would you code an Inpatient visit where the patient is intubated, severely ill and the physician is "unable to properly examine" the patient?

I know of the discussions for unable to obtain History, but not for Exam. Does the visit just fall to Problem Focused (if at least one organ system is identified)?

Thanks!

Lora

 

[FTessaBartels]

Initial or Subsequent?

If this is a subsequent hospital visit you only need two of the 3 elements - so History and MDM will give you your level

If this is a critical care visit ... the physician must document the critical nature of the patient's condition, and the CRITICAL CARE provided, as well as the total time spent face-to-face with the patient.

If this is an initial hospital visit ... well, no matter HOW cirtically ill the patient is, you have to examine him/her! How else will the physician know what to do?

Hope that helps.

F Tessa Bartels, CPC, CEMC