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Racking my brain---help

  1. #1
    Default Racking my brain---help
    Medical Coding Books
    I am auditing a chart where the physian is unable to get a full review of systems because the patient has dementia. I think I read that I can give him credit for a comprehensive since he says in his note, "unable to complete because of patient's dementia" but I can't find it in writing anywhere. Can anyone help?

    He also documents in the record that the rest of the history is obtained from the patient's spouse.

    Thanks for your help!

    Michele R. Hayes, CPC, CPMA, CEMC, CGIC

  2. #2
    Default Depends on your carrier
    WPSMedicare says no, you don't get a comphrensive in this situation. You only get credit for what you actually have.

    Laura, CPC, CPMA, CEMC

  3. Default
    It does depend on your carrier rules but the statement is in the documentation guidelines.
    Wendy P. Wright, CPC, CPMA, CEMC, CHC
    Compliance Coordinator
    CaroMont Health

  4. #4

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