Wiki patient unable to repond

[efuhrmann]

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.

 

[ollielooya]

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.

https://www.aapc.com/memberarea/forums/archive/index.php?t-6835.html

Suzanne E. Byrum CPC

 

[pkidd]

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

 

[LLovett]

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.


Laura, CPC, CPMA, CEMC