AAPC - Back to school
Results 1 to 4 of 4

Thread: unable to perform exam or obtain review of systems

  1. #1
    Join Date
    Apr 2007

    Default unable to perform exam or obtain review of systems

    AAPC: Back to School
    one of my docs was asked to give a neurological consult for a pt with altered mental status. he states he was unable to obtain a ROS because the patient was agitated, moaning, restrained, and not responsive towards questions. the patient was then given sedatives and the doc states that he was unable to perform an exam because the patient was "sleeping/sedated"

    I've got a cheif complaint, a history, vital signs, studies and tests. the MDM includes giving the patient meds and following up. the doc wants a 99221 but i don't think the "exam" qualifies.

    any thoughts?

  2. #2


    It depends if the physician is using the 1995 examination guidelines or the 1997 examination guidelines which are more detailed.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default 99499 Unlisted E/M

    It's hard to tell without seeing the actual documentation.

    Have you considered using 99499 Unlisted E/M and basing your fee on 99221?

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Join Date
    Apr 2007


    thanks, i'll try the unlisted.

Similar Threads

  1. physical exam unable to perform
    By abhishekrane32@yahoo.com in forum E/M
    Replies: 0
    Last Post: 01-11-2013, 07:51 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 the Exam
    By edieski in forum Behavioral Health
    Replies: 4
    Last Post: 03-13-2009, 03:12 PM
  4. Unable to obtain history
    By Nljacobson in forum E/M
    Replies: 10
    Last Post: 03-12-2009, 04:17 PM
  5. Unable to obtain ROS
    By abill_423 in forum E/M
    Replies: 5
    Last Post: 08-14-2008, 11:57 AM

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.