Orthocoderpgu
True Blue
Pt comes in to the ER septic and is not alert or responsive. No one is with the patient and you cant get a history. Patient has to go on a vent. Patient has High MDM and passes away five days later. Since you can't do a daily history on the patient, do you have to use MDM and exam to determine the overall level? Or could you say that since the patient was unable to respond daily, could you assume a comp HX? If I go by MDM and exam, I only get a 99232. If I go by MDM and assume comp HX since the pt is unresponsive, would this be considered a legit 99233? I appreciate your input and thoughts.