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new coder needs help with E/M

  1. #1
    Default new coder needs help with E/M
    Medical Coding Books
    If the patient is unable to communicate, but no mention of why in the physical examination, but dementia mentioned in the assessment, would this be considered a comprehensive examination?

    patient took a fall, contusion to elbow, contusion to temple area, unconscious in ER.

    physical examination: She is a 70-year old female lying in bed in no apparent distress. She is unable to communicate. She is just alert, making babbling sounds. With reference to her left lower extremity, she is somewhat shortened and flexed. Any movement of left hip creates pain.

    Assessment: Displaced subcapital fracture of the hip, demential, severe.

  2. #2
    Milwaukee WI
    Default Not comprehensive exam
    You can still examine a comatose patient. The exam is the objective findings and observations of the physician. All your physician has documented is constitutional and musculoskeletal. Possibly neurologic (because patient can't communicate and is babbling). In any case, it's an EPF exam.

    You are confusing the caveat where you can get credit for a full comprehensive history when unable to obtain due to patient's condition.

    There is no similar caveat for the exam.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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