Cardiology Coding Alert

Apply E/M Rules to Advantage When Patient Hx Isn't Possible

You can get credit for the attempt if you follow this documentation tip. Your cardiologist may sometimes perform E/M services on patients who are unable to respond to questions and can't offer a history. What will it mean for your E/M level? Here's a hint from the authorities. If You Can't Get Hx, Be Sure You Get Reason When patients present as unresponsive, mentally unstable, or even substance impaired -- especially if there's no accompanying family or caregiver -- the cardiologist may not be able to take a history, says Dorothy  Steed, CPC-H, CHCC, CPUM, CPUR, RCC, ACS-OP, CCS-P, RMC, CPC-EMS, CPC-FP, PCS, FCS, CPHM, CPAR,an independent consultant in Atlanta. When the patient is unable to give a history due to dementia or altered mental status, for example, the physician should clearly indicate why she couldn't obtain a reliable history, Steed says. Support: The 1995 E/M guidelines instruct that "if the physician [...]
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