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Thread: Racking my brain---help

  1. #1
    Join Date
    Apr 2007

    Default Racking my brain---help

    AAPC: Back to School
    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
    Join Date
    Apr 2007

    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. #3


    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
    Join Date
    Apr 2007



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