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Wiki New patient emergency visit

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AHESLER

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I work in an urgent care office and have a question on when a new patient is brought into the office maybe unconscious or unable to talk due to an emergency situation. The E/M guidelines state that you must have all 3 key components but if we are unable to obtain a full history due to the patients medical situation yet all other of the key components are met and life saving actions are taken does this mean that the code has to be lower just because the patient is unable to give a comprehensive history?
 
AHESLER said:
I work in an urgent care office and have a question on when a new patient is brought into the office maybe unconscious or unable to talk due to an emergency situation. The E/M guidelines state that you must have all 3 key components but if we are unable to obtain a full history due to the patients medical situation yet all other of the key components are met and life saving actions are taken does this mean that the code has to be lower just because the patient is unable to give a comprehensive history?
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No, you don't have to utilize the lower code automatically. The provider should document within the record which areas of the exam are unable to be completed based upon the patient's condition, it is imperative to have that documentation and then you can caveat the chart and code the chart accordingly.
 
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