# When history is unobtainable



## uadmso (Mar 12, 2013)

When a history is unobtainable (patient intubated, in a coma, etc.)  can it be counted as comprehensive, or do you just not count it at all when determining a level of E&M?  Can you site printed information that states one way or the other?


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## drashby (Mar 13, 2013)

You must document why the info was unobtainable. Per WPS, that still does not automatically give the historian a comprehensive history. Attempts to collect history andd the sources of the info must be documented to the best of the ability.


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## RebeccaWoodward* (Mar 13, 2013)

Per the documentation guidelines...

"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 that precludes obtaining a history."

Page 7

http://www.cms.gov/Outreach-and-Edu...N/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Per Palmetto Gba...

Jurisdiction 11 Part B 
E/M Weekly Tip: History Component 'Unable to Obtain'

If you are unable to obtain the review of systems (ROS) and past, family and social history from the patient/source, the documentation must *clearly* describe the patient's condition or other circumstance, which precludes obtaining a history. Example: 'Patient sedated and on a vent.  No family members present.' If the reason is related to 'dementia,' please indicate the severity of the patient's dementia. 

Once you have exhausted other resources for information, it is permissible to give credit to the provider.  As always...use good judgement.

http://www.palmettogba.com/palmetto...Center~Weekly Tips~8U5MVQ1675?open&navmenu=||


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## uadmso (Mar 13, 2013)

Thanks for your input, however my main question is how you would count the unobtainable history towards a level of service.


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## Tonyj (Mar 14, 2013)

uadmso said:


> Thanks for your input, however my main question is how you would count the unobtainable history towards a level of service.



I was informed by our MAC that credit would be ascertained by considering the other factors of severity i.e. level of PE, MDM, CC ...


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