# Unable to obtain history



## Nljacobson (Feb 6, 2009)

When coding for E/M visits, if patient is unable to provide history, I have understood the provider should document the extent of history obtained from family, review of records, patient, guardian, etc., and then the reason why they are unable to obtain additional information.

Then, determine the level of service based on exam and medical decision making, essentially taking the history out of the mix (e.g., 99221 - 99223, 99201 - 99205, 99241 - 99245, 99251 - 99255).

However, recently I was told this is a myth and one must use an unlisted E/M code if unable to obtain history.

Can someone clarify?

Thank you


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## skh_fla (Feb 6, 2009)

*Unable to get History*

Hi--I agree with you, I have not heard of the use of the unlisted code.  I have always heard (and been told in audioconferences, seminars, etc) that if the history can't be obtained from the patient then the provider should document what can be obtained from others and then the reason why history can't be gotten from the patient (comatose, dementia, etc.)


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## RebeccaWoodward* (Feb 6, 2009)

!DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Agreed...this goes completely against all the training, seminars (Medicare), workshops, etc I have had.  If they are adamant about their view, demand to see this in writing...preferably CMS.


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## RebeccaWoodward* (Feb 6, 2009)

*CASE 2 (unable to obtain): *Upon admission to the hospitalist service, an 82-year-old female presents with shortness of breath, dehydration, and confusion. The patient was transferred from her residence at a nursing
facility without accompanying records. Limited information was obtained by the emergency medical technician, and the patient is an unreliable source. The available information is documented, but the level of history is only expanded problem-focused. Can the hospitalist receive additional credit for the history?
*THE SOLUTION*
Yes. The documentation guidelines specifically reference this situation. When the physician cannot elicit historical information from the patient, and no other source is available, the physician should document that he is “unable to
obtain” the history and the circumstances surrounding this problem (e.g., patient confused, no caregiver present). The hospitalist can receive “complete history” credit for his attempted efforts.

http://www.the-hospitalist.org/uploads/articles/THApril2008Article101.pdf

I just found this also...is your carrier WPS?
*
What do I do if my patient is a poor historian or a history cannot be obtained? *
First, you must always document the facts surrounding the reason you were unable to obtain the history. Keep in mind that in this scenario, you may be able to obtain the history from other providers, family or friends. If no history is obtainable you must choose your level of service based on the following:

If the service requires two of three key elements per CPT requirements (e.g. established or subsequent hospital patient), report the level of service based on the examination and MDM elements. 
If the service provided requires three of three key elements to be met or exceeded (e.g. new patient, consultation, initial hospital care) report the level of service based on the payer. 
WPS Medicare Part B: Report Unlisted Code 99499 
When choosing a fee for an NOC code, the physician should bill the amount he or she believes reflects the quantity of work performed in the service. 
The AMA does not have documentation requirements for choosing levels of service. The reply we received from them on this question was to adhere to the CMS 95' or 97' Documentation Guidelines.


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## 1073358 (Feb 9, 2009)

I have been listening to the Medicare lunchtime teleconferences that started last week. In there it said that if you can not obtain a history or ROS, you can only code the LOS it comes to without that or bill the 99499, whichever is to your benefit. 

You can not just give the provider credit for a full ROS or hx, just because he cant get it. 

I do not think that is fair at all, but that is what it said.


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## Bigasammie (Mar 10, 2009)

*Unable to obtain History*

Can anyone out there direct me to CMS guidance on this situation?
I would love to be able to tell my physicians that they can get full "credit" for the History if they simply document the reason it is not obtainable.
I would like the "permission" to come from CMS.
Thanks,
Sharon


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## RebeccaWoodward* (Mar 10, 2009)

!DG: If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history.

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

Page 8

When a physician is unable to obtain a history, the record should describe the circumstances which preclude him/her from obtaining it.  You should also check with your particular contractor since some Medicare carriers will not allow this type of documentation.  Our carrier happens to allow this type of documentation for a qualifying event.


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## rthames052006 (Mar 10, 2009)

rebeccawoodward said:


> !DG: If the physician is unable to obtain a history from the patient or other
> source, the record should describe the patient's condition or other
> circumstance which precludes obtaining a history.
> 
> ...




I have always done what you are telling the others to do, I also think it would be a carrier decision.  I see you referenced WPS.  I am known for calling my specific carriers to find out their rules/guidelines; sometimes it gets to be alot of info to remember for specific carriers... I've come to make up a grid for my carriers or should I say our "more frequent" carriers, this way I know what I'm doing and am keeping it as straight as I can.


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## RebeccaWoodward* (Mar 10, 2009)

I agree Roxanne.  It can be difficult to keep up with all the rules and policies of other carriers.  Our rule of thumb...when it comes to coding conventions, we follow one rule of thumb and deal with the carrier one on one for a denial of a claim. However, it comes to documentation guidelines, we rely soley on our Medicare carrier.  Since most of *our *other carriers typically follow our Medicare's contractor guidelines, I feel that I have a legitimate leg to stand on in the event of an audit.  I find that traditional coding conventions are becoming more difficult to appeal since carriers are implementing their own edits.  Of course...I fiercely appeal these.


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## Bigasammie (Mar 12, 2009)

Thank you. I've seen the section you referenced but I want to see the next part....where the physician receives full credit for the History component.
Highmark is my carrier. I am awaiting for a response from them.


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## rthames052006 (Mar 12, 2009)

rebeccawoodward said:


> I agree Roxanne.  It can be difficult to keep up with all the rules and policies of other carriers.  Our rule of thumb...when it comes to coding conventions, we follow one rule of thumb and deal with the carrier one on one for a denial of a claim. However, it comes to documentation guidelines, we rely soley on our Medicare carrier.  Since most of *our *other carriers typically follow our Medicare's contractor guidelines, I feel that I have a legitimate leg to stand on in the event of an audit.  I find that traditional coding conventions are becoming more difficult to appeal since carriers are implementing their own edits.  Of course...I fiercely appeal these.



Rebecca... I agree with your point on following the Medicare contractors documentation guidelines... it gets to be too sticky sometimes, do you notice how if another carrier doesn't like the "medicare" guideline they just do their own thing... It's so much to keep up with anymore... I think we as coders need to all understand the "compliance" side of things as well, which is something I am really starting to get into or should I say have always been into but didn't realize how much I am relying on it nowadays...


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