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  1. Default caveat
    Medical Coding Books
    Can I use the caveat if the dr states in the hpi, loc pt found lethargic pt with similar problem in past work up reported negative, gcs = 10? thanks alice

  2. #2
    I would want more documentation than what you have posted explaining why the history is incomplete and attempts to utilize other sources for patient info to apply the caveat.

    The Level 5 Caveat (Top)
    The definition of 99285 includes the concept that the History, Physical Exam, and Medical Decision Making requirements must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". Most Medicare carriers require a description of the patient's urgent condition and the physician's thought process. So make sure to document why the severity of your patient's illness precludes performing a full History or Exam.

    An article from AAPC:

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