Wiki Exam When Patient is Unarousable

[j.berkshire]

When a patient is unarousable, and CNs are not examined, do you count these towards the level of examination?

We have instruction from CMS addressing a ROS that is unobtainable, but I have found no guidance for the same situation with the physical exam.

Thoughts and comments are appreciated and thanks,

 

[RebeccaWoodward*]

Palmetto GBA

Per Palmetto GBA:

Jurisdiction 11 Part B

E/M Weekly Tip: Acuity Caveat (Examination)

The acuity caveat (unable to obtain) does not apply to the Examination component; it only applies to the History component.

http://www.palmettogba.com/palmetto...Center~Weekly Tips~987PHS5427?open&navmenu=||

 

[Pam Warren]

The exam is an objective finding (meaning, not needing patient input) by the physician. Some elements of examination can be done without patient being participatory, aware or even conscious. We instruct our physicans to do as much of the exam as possible, regardless of patient's condition, if an examination is warranted to support the nature of the presenting problem. They certainly can examine the patient when they're unresponsive (think about the ICU...or post-surgical). Otherwise, particularly in the ED, for new patients or for inpatient/osv initial visits, they will not meet the three key components necessary to report the service.