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Unable to obtain history-Admission

  1. #1
    Default Unable to obtain history-Admission
    Medical Coding Books
    Okay, I am also having a 'Friday Brain Fart'. I am trying to audit an admission. The physician states they are unable to obtain any information from the patient because they are unwilling to speak. The information obtained is limited from the HHA.
    Question, is an admission code allowed even though you are missing PSHx because the patient is unwilling to speak?


  2. #2
    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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