# "Unresponsive" patient E/M level



## Alisa Dinneen (Jul 7, 2009)

Can anyone give me guidance on E/M coding if the patient is unresponsive due to trauma and intoxication (MVA) -- does it automatically pull my E/M leval down to the lowest level because the physician cannot obtain any history or system review?  The exam is comprehensive and complexity of MDM is high.

Thank you,
Alisa


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## RebeccaWoodward* (Jul 7, 2009)

Could the history be obtained from family members or another authoritative source?  If not, Medicare does have a caveat in place for this situation.

"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".

The physician should thoroughly document why he can't obtain this information.  i.e. unable to obtain history from patient due to XXX.  No family members available.

This would allow he/she to receive credit for this scenario

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

page 8 (under 97 DG)


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## mitchellde (Jul 7, 2009)

The E&M guidelines that I have state that if the patient is unable to communicate and it must be documented then history is considered comprehensive.  Things like unresponsive, and unconscious were given as examples.


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## dballard2004 (Jul 8, 2009)

Debra,

Can you share the link to those guidelines.  I agree with you, I just want to have this in writing.  Thanks.


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## Alisa Dinneen (Jul 9, 2009)

Thank you all for your responses--most helpful!

Alisa


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## maudys (Jul 9, 2009)

EMERGENCY DEPARTMENT SERVICES

The options for "Emergency Patient's Condition" are:  1) Critical, unable to give history, or 
2) Other

If you choose 1 - (critical), the following message appears:

"The urgency of the patient's clinical condition and/or mental status may preclude obtaining a comprehensive history.

The constraints imposed by the urgency of the patient's clinical condition and/or mental status should be indicated in the documentation..", and a comprehensive history is assigned.

This is provided by the 3M coding software NOSology message 4854.


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