Bernadette10
Guru
Inpatient consultation - When a provider is unable to obtain a ROS and documents why but doesn't say anything about trying to get it from other sources, can I still give credit for a comprehensive history if all the other elements are there? Or would this be a detailed history with just 2 ROS for the urinary (voiding) and psych (confusion)? I would give this a detailed history.
A 67 y.o. male admitted for altered mental status with hx of cirrhosis, hep C, encephalopathy who traumatically removed his catheter early this morning. Nursing noted a small amount of blood at the meatus but reports the patient has been voiding. Platelets noted to be 73, INR 2.2. The patient is confused and cannot provide urologic history at this time.
Review of Systems
Unable to perform ROS: Mental acuity
Past Medical History
Arthritis
Family History
Father, mother, brother healthy
Social History
Former smoker
Physical Exam
Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress. No distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light.
Neck: Neck supple.
Cardiovascular: Normal rate.
Pulmonary/Chest: Effort normal.
Abdominal: Soft. He exhibits no distension and no mass. There is no abdominal tenderness. There is no rebound and no guarding.
Genitourinary: Penis normal.
Genitourinary Comments: Blood at meatus
Musculoskeletal:
General: No tenderness or edema.
Neurological: He is alert and oriented to person, place, and time.
Skin: Skin is warm. He is not diaphoretic.
Psychiatric: Affect normal.
Nursing note and vitals reviewed.
Assessment
Hematuria, traumatic Foley removal
Plan
-recommend observing urethral bleeding for now
-if continues or if patient is unable to urinate, replace foley
-follow hct
-please contact me for ongoing issues
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00005056
10. When a physician performs an E/M service and the patient is not able to provide history, if the physician documents “patient in a coma,” “patient not able to respond,” “patient unresponsive,” can they count a comprehensive history?
When a physician performs an E/M service and is unable to obtain parts of the history component for that encounter, documentation should clearly reflect the components that were not obtained (HPI, ROS and/or PFSH). Documentation should also include why the components were not obtained (patient unresponsive, sedate on a vent, etc.), and attempts to obtain information from other sources; such as a family member, spouse, nurse, etc. When the Clinical Reviewers are reviewing documentation, it is reviewed in its entirety. If the documentation clearly supports that the patient is not able to provide the information necessary (history components) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited.
A 67 y.o. male admitted for altered mental status with hx of cirrhosis, hep C, encephalopathy who traumatically removed his catheter early this morning. Nursing noted a small amount of blood at the meatus but reports the patient has been voiding. Platelets noted to be 73, INR 2.2. The patient is confused and cannot provide urologic history at this time.
Review of Systems
Unable to perform ROS: Mental acuity
Past Medical History
Arthritis
Family History
Father, mother, brother healthy
Social History
Former smoker
Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress. No distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light.
Neck: Neck supple.
Cardiovascular: Normal rate.
Pulmonary/Chest: Effort normal.
Abdominal: Soft. He exhibits no distension and no mass. There is no abdominal tenderness. There is no rebound and no guarding.
Genitourinary: Penis normal.
Genitourinary Comments: Blood at meatus
Musculoskeletal:
General: No tenderness or edema.
Neurological: He is alert and oriented to person, place, and time.
Skin: Skin is warm. He is not diaphoretic.
Psychiatric: Affect normal.
Nursing note and vitals reviewed.
Assessment
Hematuria, traumatic Foley removal
Plan
-recommend observing urethral bleeding for now
-if continues or if patient is unable to urinate, replace foley
-follow hct
-please contact me for ongoing issues
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00005056
10. When a physician performs an E/M service and the patient is not able to provide history, if the physician documents “patient in a coma,” “patient not able to respond,” “patient unresponsive,” can they count a comprehensive history?
When a physician performs an E/M service and is unable to obtain parts of the history component for that encounter, documentation should clearly reflect the components that were not obtained (HPI, ROS and/or PFSH). Documentation should also include why the components were not obtained (patient unresponsive, sedate on a vent, etc.), and attempts to obtain information from other sources; such as a family member, spouse, nurse, etc. When the Clinical Reviewers are reviewing documentation, it is reviewed in its entirety. If the documentation clearly supports that the patient is not able to provide the information necessary (history components) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited.