Wiki Inpatient Level 5 Consult - Demented Patient

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CrysLednum

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Hi - I have a doctor who wants to charge a level 5 (99255) for a consult he did in the hospital on a patient who is demented. I performed the audit using Medicare's E/M audit sheets and while he has 2 components that are comprehensive, his history portion is only a level 2. His question is doesn't Medicare allow a level 5 when the patient is demented. I have not found anything to support this. Maybe I have missed something? Thanks!
 
There is a clause in the guidelines for history that states if the patient is unable to relate history due to some condition, (they give unconscious as an example) then history is considered to be comprehensive.
 
It is in the part on DG in the history section , here I clipped it for you:
!DG: If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history.
this means the hx can be determined comprehensive.
 
I would check with your carrier to find out what they allow. WPSMedicare does not allow for a comprehensive history in this scenario.

Laura, CPC, CEMC
 
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