Wiki e/m levels for non verbal

[lambertj]

just had a patient who is autistic and non verbal. the encounter very well could of been a new patient 3 had the person been able to talk.. though there was not identification of how much time was spent.. I ended up just giving a 2. which brings me to my question.. should the persons ability to communicate be able to affect the cost of the encounter? just wanted a few oppinions.

 

[FTessaBartels]

Patient's ability is not what is affecting the coding

It's not the patient's inability to talk that is affecting the coding.... it's the physician's documentation.

Did he have to obtain history from the patient's relative or caregiver? From the patient's records at a nursing or group home? From a referring provider?

The lack of documentation to bill a higher level service rests solely on the physician's shoulders.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[MikeEnos]

It's not the patient's inability to talk that is affecting the coding.... it's the physician's documentation.

Did he have to obtain history from the patient's relative or caregiver? From the patient's records at a nursing or group home? From a referring provider?

The lack of documentation to bill a higher level service rests solely on the physician's shoulders.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Agreed. If the provider documented the length of the encounter, and how he counselled the parents/caregivers.... or documented getting history from someone other than the patient... or even documenting what review of systems he can ascertain, then stating that the rest of the ROS was unobtainable because the patient is nonverbal, then the history is not limited.

The patient being non-verbal DID NOT limit the potential reimbursement. The only thing that would limit the potential reimbursement is the provider's insufficient documentation of the complexity of the case.