Could the history be obtained from family members or another authoritative source? If not, Medicare does have a caveat in place for this situation.
"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 should thoroughly document why he can't obtain this information. i.e. unable to obtain history from patient due to XXX. No family members available.
This would allow he/she to receive credit for this scenario
page 8 (under 97 DG)
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