Wiki Unobtainable history


Tujunga, CA
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Can somebody provide me with a written instruction from a reliable source, ie, CMS, etc. for unobtainable history and what level should be assigned?
For example, if my physician performed a comprehensive exam and made a comprehensive medical decision, and he documented that he could not obtain history from patient (obtunded), nor from family, past medical records, paramedic, etc., I need something in writing that says I can also add a comprehensive history and make the overall level of E/M comprehensive. Thank you.
Hi. I have been doing ED professional coding, auditing, and physician documentation training for about 13 years.

If any or all portions of the history are unobtainable, and every effort has been made to get the information from other sources--including attempting to get the information later in the visit if possible, this is considered a level 5 caveat in ED professional coding. I would think it is also applicable to other E/M codes as well. CMS DG (Documentation Guidelines) 1995 and 1997 state: "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history." The physician would have to state which history area is unobtainable, as applicable--for example, PFSH could be obtainable from the medical record and a partial ROS should be available from bystanders, family, caregivers or EMT's. He would also have to state why it is unobtainable (intubated, obtunded, altered mental status, etc.) and the medical record should support this. If the rest of the documentation supports a comprehensive E/M level (high medical decision making, comprehensive PE)--I would feel comfortable coding a high level E/M. Kathy R, CPC. Oregon
This applies only for ED that too if documentation satisfies other parameters for assigning 99285. Because the code description for 99285 in the CPT book allows this. For the other E/M services it is better to bill with 99499 if history is unobtainable.

Hope this helps!
WPS Medicare Part B answered this question in a teleconference. They said that although the fact that history could not be obtained is taken into consideration, it's not a guarantee they'll find it to be comprehensive. Here's the webaddy to view the questions and answers:

Personally, I'm not sure about using a 99499 because the history was unobtainable. Might you reply to the posting with information on why one would use 99499 on this, eg., did your carrier tell you to do that, a CMS document we're not aware of, policy in your company, etc?


The following in an excerpt from Medicare Claims Processing Manual, Chapter 12:

"In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed)."

Thanks for the info. I do see your point, yet this isn't just one component of an E/M. The provider was able to do everything except get the history. 2 of three key components are still happening. The quote is great, and it provides a specific notation of "e.g., only a history is performed", yet from the sounds of it, and what I'm used to seeing, is that only the history isn't being able to be taken. My personal opinion is still to choose a level of E/M versus a 99499, unless only one key component is being performed. I would base the E/M level on the lower of the two key components that were able to be performed. Just my two cents there:)

I believe it would be appropriate to count for the history as the provider attempted to obtain it; as long as the provider documents the attempt and the reason, they should get full credit for the admission.