sallycase1
New
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.
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.