# Unable to obtain History



## lchristy (Sep 11, 2010)

Hi all, 

If my Doc states he was unable to obtain a history from the patient due to unconsciousness, but describes the condition of the patient in the note, can he get credit for a comprehensive history?? Doc is wanting to bill out a level 5 consult, however, not able to get a history. Is there a guideline that addresses this type of issue. 

thanks in advance for your help!!
Leah


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## kbarbag (Sep 12, 2010)

Highmark Medicare does give credit as comprehensive.  check your carriers web site. Highmark has E&M area that address most audit questions. 
Auditing hand book I got from AMA also states to give credit for comprehensive. they have to state ""Unable to obtain history due to _____" Or "Pt is poor Historian"


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## lchristy (Sep 13, 2010)

thank you for your response, much appreciated!!

Leah


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## FTessaBartels (Sep 29, 2010)

*Hospitalized patient?*

I'm assuming this *unconscious* patient is hospitalized ... there is a hospital chart that the physician can read to obtain the history. The physician can simply document: I reviewed the ROS and PFSH from the patient hospital chart for this admission. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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