• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

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