I code for Hospitalists and they see many nursing home patients in the ER and we come up against this scenario quite often! I asked this question to Highmark, our Medicare carrier, and I was told as long as you document the circumstance of why the patient is unable to answer your ROS questions (dementia, unresponsive, ect.) and you document what steps you took to obtain this information (i.e. spoke with family by phone, nursing staff or caregivers, family not available, old medical records, etc.) then you can qualify for a comprehensive History. The doctor must still perform the comprehensive exam and MDM portion to get your level.
Hope this helps!
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