ED Coding and Reimbursement Alert

Question: How does CMS audit records when the acuity caveat is used to explain the ED physician's inability to obtain information? Specifically, does the physician have to write a note that states, "Unable to obtain info due to ... no other source available"? Or does the auditor consider the entire medical record (the nurse's notes, EMS notes, etc.)?

Utah Subscriber Answer: According to the 1995 documentation guidelines, if the history is unobtainable, the physician should state the reasons why and whatever alternative sources he pursued.
 
Using an "implied caveat" from the nurse's notes is a gray area and not foolproof. Taken to an extreme, a patient with active cardiopulmonary resuscitation would be impossible to get a history from directly - but the family and EMS might be available to comment.
 
Rather than leaving it up to the good graces of the auditor, you're best off having the doctor state why the history was unobtainable and what sources were consulted, and thereby give the auditor no room for criticism.