I know with my local medicare carrier, if the doc is unable to obtain info from the pt for medical reasons and it's documented he does get credit for a complete in that area of auditing.
I don't know in your case if that would fly, if the pt is "unwilling" to speak, do you know if there were any family members in the room at the time of the service.
I would check with the carrier on that one, in this particular case.
Roxanne Thames, CPC
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