patient unable to repond


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What is the rule when an unconscious patient admitted after police found him on the sidewalk? How do I audit the HPI and ROS? "The patient is an unknown white male found down on the sidewalk by police. He is somnolent and unable to give any history. ROS/PFSH could not be obtained due to the fact that the patient is unresponsive." I just need the history level.
To get the thread started, did some research...

Elizabeth I'm sure you probably are aware of the 97 guidelines that state: 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.

Furthermore I did some digging in the archives here because I'm interested in the answer to your question as well. It is older stuff, but may stlll be relevant.

Suzanne E. Byrum CPC
Found down / unable to reply

Greetings Elizabeth,

I work for trauma surgeons & we see this scenario with some regularity.

The E&M charges you bill will depend on your physician's documentation just like any other case. The physician must document all that he/she knows about the patient's circumstance that brought him to the ED/hospital. Physician must document patient's level of conscious and his inability to respond to ROS, PFSH, etc. Physician must document that he/she is unable to elicit any information from or about the patient. Physician should also document that he/hospital has tried locating previous medical records and/or family members or friends and the result. If physician obtains information from EMS; he should also document this.

I hope this was helpful. Good luck!
pat kidd
Check with your carrier

WPSMedicare would direct us towards an unlisted code for this E/M if it didn't qualify for anything else, like critical care.