Ethanzoe
Contributor
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!
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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