Wiki We got a legit 99233 ??

[Orthocoderpgu]

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.

 

[lporter]

https://www.cms.gov/MLNProducts/downloads/referenceI.pdfDG:
Page 5, 1995 E/M documentation guidelines

https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
Page 6, 1997 E/M documentation guidelines

DG: 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.

 

[FTessaBartels]

Critical Care

Your provider needs to be educated about critical care. A patient who is this sick most likely met the definition of critically ill. The physician treating said patient (at least on admission) most likely spent at least 30minutes in direct critical care.

Did no family members EVER show up during the patient's hospitalization? You can complete the history on a later date. Also usually you only need an interval history - can be reported by hospital staff: E.g. Overnight patient remained stable as per documented vitals; vent settings unchanged.

Hope that helps.

F Tessa Bartels, CPC, CEMC