CASE 2 (unable to obtain): Upon admission to the hospitalist service, an 82-year-old female presents with shortness of breath, dehydration, and confusion. The patient was transferred from her residence at a nursing
facility without accompanying records. Limited information was obtained by the emergency medical technician, and the patient is an unreliable source. The available information is documented, but the level of history is only expanded problem-focused. Can the hospitalist receive additional credit for the history?
THE SOLUTION
Yes. The documentation guidelines specifically reference this situation. When the physician cannot elicit historical information from the patient, and no other source is available, the physician should document that he is “unable to
obtain” the history and the circumstances surrounding this problem (e.g., patient confused, no caregiver present). The hospitalist can receive “complete history” credit for his attempted efforts.
http://www.the-hospitalist.org/uploads/articles/THApril2008Article101.pdf
I just found this also...is your carrier WPS?
What do I do if my patient is a poor historian or a history cannot be obtained?
First, you must always document the facts surrounding the reason you were unable to obtain the history. Keep in mind that in this scenario, you may be able to obtain the history from other providers, family or friends. If no history is obtainable you must choose your level of service based on the following:
If the service requires two of three key elements per CPT requirements (e.g. established or subsequent hospital patient), report the level of service based on the examination and MDM elements.
If the service provided requires three of three key elements to be met or exceeded (e.g. new patient, consultation, initial hospital care) report the level of service based on the payer.
WPS Medicare Part B: Report Unlisted Code 99499
When choosing a fee for an NOC code, the physician should bill the amount he or she believes reflects the quantity of work performed in the service.
The AMA does not have documentation requirements for choosing levels of service. The reply we received from them on this question was to adhere to the CMS 95' or 97' Documentation Guidelines.