Wiki E/M coding help please...

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asasands

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Our surgeon did a consult in the ICU. No time was documented and it is documented that a ROS could not be obtained because of his condition. The patient is 92 year-old sepsis patient and is not really responsive. A complete PE was done and HPI...what code would you use?

Thanks

Stacey
 
This is a tough one.... Assuming this is not Critical Care.... Things to remember: Good the surgeon documented non-responsive due to sepsis or "Nature of the Presenting Problem" is allowed; an interval history is allowed for inpatient visits. As stated above, you have a complete PE and HPI (an interval history is allowed), it appears that all you need is the medical decision making to choose a CPT. If the pateint has Medicare, it would be best to choose an initial inpatient code (99221-99223), not a consult CPT. Maybe even choose an ICD-9 appropriate to the consult request.
 
Why couldn't he get history from the chart?

Was the patient brought in unresponsive and without any family (or nursing home records) to provide any history?

In these cases, the physician should at least review/refer to the history in the chart, and THEN indicate unable to add any update due to unresponsive patient and no family present.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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