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Unresponsive patient and E/M leveling

M

mollie77

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A patient is unresponsive during assessment by psychiatrist for whatever reason (catatonic, sedated, uncooperative, etc.). As long as the doctor documents that he/she was unable to obtain necessary info from patient and why, can I consider this a comprehensive history and exam? I keep hearing opposite opinions on this matter. Thanks!!
 
You can credit only the comprehensive HPI/ROS. You may not credit a comprehensive exam. The exam is done objectively by the provider, and can be completed even if the patient is not responsive. An exam must be done if you want credit, regardless of patient's condition.

If he chooses to not do an exam, you would have to calculate your E&M code only on HPI and MDM.
 
Check with your carrier!

I had always been taught that YES, you could count it as comprehensive history as long as the reason why the information could not obtained was documented.

BUT ...

At an E/M symposium sponsored by the Wisconsin Medical Society last fall our panelist from WPS Medicare stated that if you are unable to obtain the full ROS or PMFSH then you cannot have a comprehensive history and must use the unlisted E/M 99499 code. We were discussing initial hospital visits specifically.

So, check with your carrier.

F Tessa Bartels, CPC, CEMC
 
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