E & M Pt unable to provide Histoy

Diana2032

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Good afternoon,

I'm new to E& M coding and I'm coding and in-pt consultation where the pt is unable to provide hx nor ROS because he speaks no English, the note reads "the family recently noticed foul-smelling drainage around his PEG site. History is obtained from chart review as the patient does not provide any history, nor is he able to speak English. The patient was found to be increasingly lethargic and the family became concerned and brought him to the hospital. Since being in the hospital the pt was found to have migration of the PEG tube into his tranfers colon with possibly peritonitis and other infectious issues. I was asked to help assist in the management of his chronic atrial fibrillation". I'm coding for the cardiologist seeing the pt. So far I can only get Location.....Please help!!! :D

Thank you,

D.B, CPC, CPMA, CCA
 
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jimbo1231

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Caveat?

I think you can get quality with "foul smelling". But patient is clearly unable to provide history and the family is pretty limited as well. You might have a history caveat. Would be stronger case if physician clearly documented that history is limited for all the reasons given. Also I'm guessing this is not a Medicare patient if you are trying to code a consult. Jim
 

Diana2032

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I think you can get quality with "foul smelling". But patient is clearly unable to provide history and the family is pretty limited as well. You might have a history caveat. Would be stronger case if physician clearly documented that history is limited for all the reasons given. Also I'm guessing this is not a Medicare patient if you are trying to code a consult. Jim

Thanks Jim!! Yes this is a Medicare pt I will be using initial in-pt codes 99221-99223. I was under the impression that if the pt is unable to provide history and/or review of systems the physician automatically gets full credit for the attempt. Based on the information the provider documented I think the overall history level would be expanded problem focus, am I right? Thank you.
 

mitchellde

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However, I am not certain that unable to speak English will qualify as a circumstance where you can consider the patient unable to render history. It seems that the patient could, just that the physician did not speak the same language. You need to check, but I believe it is the responsibility of the provider or facility to provide for the interpreter.
 

Diana2032

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However, I am not certain that unable to speak English will qualify as a circumstance where you can consider the patient unable to render history. It seems that the patient could, just that the physician did not speak the same language. You need to check, but I believe it is the responsibility of the provider or facility to provide for the interpreter.

Thank you Debra!!
 
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