• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Exam When Patient is Unarousable

Create Wiki
J

j.berkshire

Guest
Messages
244
Location
Dayton
Best answers
0
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,
 
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.
 
You must log in or register to reply here.
Top