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Thread: Coding SNF E&Ms when HX unobtainable--help!

  1. #1

    Question Coding SNF E&Ms when HX unobtainable--help!

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    I have nurse practitioners that visit patients in nursing facilities. Pts may not be able to respond due to dementia, alzheimer's, etc.
    I'm looking for specific guidelines to best code E&Ms when information is unobtainable from pt.
    Any ideas??
    From the E&M guidelines, it states that if the phys is unable to obtain a hx from pt or other source, then the record should be noted as such. My question is, what level? In research I've found many say it's comprehensive, but I haven't found anything from CMS that states that.

    Last edited by missyd; 01-31-2008 at 08:38 AM.

  2. #2


    I found this in Medicare Report/March 1, 2005:

    Q: If a patient is comatose or otherwise unable to provide a medical history, what does a physician need to document to obtain credit for "all others negative" in the ROS section of the History component?

    A: When a patient is unable to communicate with the physician, credit will be given for a comprehensive History component (HPI, ROS, and PFSH), if the physician documents 1) Why the patient cannot communicate, and 2) What attempts the physician made in a diligent effort to obtain information from another source; e.g., a family member or nursing facility staff member.[/I][/I]

    Maybe you can use this info as a starting point.

  3. #3
    Join Date
    Apr 2007
    Hamden, CT

    Default hope this helps

    I would start by having my doc review the W-10 formfrom the SNF because it should document the patients history throughly, the MD or NP should record that he/she reviewed the patients documented history and refer to the form and/or care coordinator for the SNF, you should code the visit as if the W-10 was a intake form.

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