Because the patient was on a mechanical ventilator your physician has a reason for not being able to take a complete ROS.
However, if the physician is relying on the medical record, he should indicate where in the record he obtained the information (e.g. H&P dated 3-10-09), and also indicate that he reviewed this information.
Depending on how the rest of the documentation is written, I'd be inclined to give him credit for 99252 in this case because there is a presumption of a shared medical record for an inpatient and he at least mentioned that it is in the record.
Another question for you ... as the patient is on a ventilator s/he is probably critically ill. Did you physician provide critical care services?
F Tessa Bartels, CPC, CEMC
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