Wiki Please help....I'm racking my brain!

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mhcpc

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I am auditing a chart where the physian is unable to get a full review of systems because the patient has dementia. I think I read that I can give him credit for a comprehensive since he says in his note, "unable to complete because of patient's dementia" but I can't find it in writing anywhere. :( Can anyone help?

He also documents in the record that the rest of the history is obtained from the patient's spouse.

Thanks for your help!

Michele R. Hayes, CPC, CPMA, CEMC, CGIC
 
May depend on your carrier

This may depend on your carrier. At the last Medical Society of Wisconsin Coding Symposium on E/M coding in October 2009 our WPS Medicare representative stated specifically that no credit is given for such missing information ... we were instructed to use 99499 Unlisted E/M in these cases, and submit with supporting documentation.

F Tessa Bartels, CPC, CEMC
 
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