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Cardiology Coding Alert

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

Published on Sun Jul 26, 2009

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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