# Comprehesive history - patient is intubated



## Love Coding! (Jun 15, 2012)

Hello,

Does anyone know if the patient is intubated and a history cannot be obtained and the physician list why, by default would this be considered a comprehensive history?  (extended HPI, 10+ systems reviewed and all three areas of the PFSH).  If this helps my physicians are in Nevada (Palmetto GBA J1) and Arizona (Noridian).  I have checked both websites and did not give me any insight about the HPI.

Thank you,


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## mcandia (Jun 15, 2012)

*Comprehensive history - patient is intubated*

Defaulting to a comprehensive history pertains to ROS and PFSH components only and does not include the HPI.

A history / HPI has to be obtained / documented whether by review of records, family member etc. 

As long as the detail with a statement such as "unable to obtain patient's ROS & PFSH due to patient intubated, unresponsive etc. then this would qualify as comprehensive for these areas.

Maria


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## aimie (Jun 15, 2012)

*History*

I am taking the E/M online training.  What do u mean by default.  Can u explain little further.  I am trying to keep my skills fresh while I am looking for work. 

Thank You

Aimie


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## mcandia (Jun 16, 2012)

*Comprehensive history - patient is intubated*

"By default" just means that the scoring / obtainment of "comprehensive" was achieved in lieu of obtaining these items from the patient for a stated reason i.e., patient intubated, unresponsive etc. 

Maria CPC, CPC-H, CPCO, CPMA, CEMC


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