E&M and patient is unable to give a history

Ethanzoe

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Hello,

I have an E&M question. When reviewing the history to choose a level whether initial or subsequent IP or Observation; often the the statement will clearly say unable to give reliable history due to dementia, mental retardation/nonverbal, unconscious ect. I keep finding conflicting info that states it can not be counted as a history at all and other places state it can be counted as a complete review as long as it is documented why the history can not be obtained. If anyone can give clarity or a link to pertinent info I would greatly appreciate it.

Thank you and have a good day!
 
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swelch

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history

DG: 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 circumstance which precludes obtaining a history.


this is found in the CMS E&M Evaluation Guide. on page 29.
 
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