Wiki Unable to obtain History

Create Wiki
L

lchristy

Contributor
Messages
10
Location
Chester, NH
Best answers
0
Hi all,

If my Doc states he was unable to obtain a history from the patient due to unconsciousness, but describes the condition of the patient in the note, can he get credit for a comprehensive history?? Doc is wanting to bill out a level 5 consult, however, not able to get a history. Is there a guideline that addresses this type of issue.

thanks in advance for your help!!
Leah
 
Highmark Medicare does give credit as comprehensive. check your carriers web site. Highmark has E&M area that address most audit questions.
Auditing hand book I got from AMA also states to give credit for comprehensive. they have to state ""Unable to obtain history due to _____" Or "Pt is poor Historian"
 
Hospitalized patient?

I'm assuming this unconscious patient is hospitalized ... there is a hospital chart that the physician can read to obtain the history. The physician can simply document: I reviewed the ROS and PFSH from the patient hospital chart for this admission.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
You must log in or register to reply here.
Top