Hi. I have been doing ED professional coding, auditing, and physician documentation training for about 13 years.
If any or all portions of the history are unobtainable, and every effort has been made to get the information from other sources--including attempting to get the information later in the visit if possible, this is considered a level 5 caveat in ED professional coding. I would think it is also applicable to other E/M codes as well. CMS DG (Documentation Guidelines) 1995 and 1997 state: "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 would have to state which history area is unobtainable, as applicable--for example, PFSH could be obtainable from the medical record and a partial ROS should be available from bystanders, family, caregivers or EMT's. He would also have to state why it is unobtainable (intubated, obtunded, altered mental status, etc.) and the medical record should support this. If the rest of the documentation supports a comprehensive E/M level (high medical decision making, comprehensive PE)--I would feel comfortable coding a high level E/M. Kathy R, CPC. Oregon
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