Wiki "Unresponsive" patient E/M level

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Alisa Dinneen

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Can anyone give me guidance on E/M coding if the patient is unresponsive due to trauma and intoxication (MVA) -- does it automatically pull my E/M leval down to the lowest level because the physician cannot obtain any history or system review? The exam is comprehensive and complexity of MDM is high.

Thank you,
Alisa
 
Could the history be obtained from family members or another authoritative source? If not, Medicare does have a caveat in place for this situation.

"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 should thoroughly document why he can't obtain this information. i.e. unable to obtain history from patient due to XXX. No family members available.

This would allow he/she to receive credit for this scenario

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

page 8 (under 97 DG)
 
The E&M guidelines that I have state that if the patient is unable to communicate and it must be documented then history is considered comprehensive. Things like unresponsive, and unconscious were given as examples.
 
EMERGENCY DEPARTMENT SERVICES

The options for "Emergency Patient's Condition" are: 1) Critical, unable to give history, or
2) Other

If you choose 1 - (critical), the following message appears:

"The urgency of the patient's clinical condition and/or mental status may preclude obtaining a comprehensive history.

The constraints imposed by the urgency of the patient's clinical condition and/or mental status should be indicated in the documentation..", and a comprehensive history is assigned.

This is provided by the 3M coding software NOSology message 4854.
 
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