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Thread: Unable to obtain History

  1. #1

    Default Unable to obtain History

    AAPC: Back to School
    Hi all,

    If my Doc states he was unable to obtain a history from the patient due to unconsciousness, but describes the condition of the patient in the note, can he get credit for a comprehensive history?? Doc is wanting to bill out a level 5 consult, however, not able to get a history. Is there a guideline that addresses this type of issue.

    thanks in advance for your help!!

  2. #2


    Highmark Medicare does give credit as comprehensive. check your carriers web site. Highmark has E&M area that address most audit questions.
    Auditing hand book I got from AMA also states to give credit for comprehensive. they have to state ""Unable to obtain history due to _____" Or "Pt is poor Historian"

  3. #3


    thank you for your response, much appreciated!!


  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Hospitalized patient?

    I'm assuming this unconscious patient is hospitalized ... there is a hospital chart that the physician can read to obtain the history. The physician can simply document: I reviewed the ROS and PFSH from the patient hospital chart for this admission.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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