Results 1 to 4 of 4

Unable to obtain History

  1. #1
    Default Unable to obtain History
    New Call-to-action
    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
    Milwaukee WI
    Default Hospitalized patient?
    Medical Billing
    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

Similar Threads

  1. Replies: 2
    Last Post: 07-01-2013, 03:51 PM
  2. Unable to obtain history
    By svrastil in forum E/M
    Replies: 2
    Last Post: 04-23-2009, 11:33 AM
  3. Unable to obtain history
    By Nljacobson in forum E/M
    Replies: 10
    Last Post: 03-12-2009, 04:17 PM
  4. Unable to obtain ROS
    By abill_423 in forum E/M
    Replies: 5
    Last Post: 08-14-2008, 11:57 AM
  5. Unable to obtain history-Admission
    By dwmt1 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 01-11-2008, 01:38 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.