Inpatient Facility Coding & Compliance Alert
Let the Physician State Reason for Not Obtaining History
Question: How does CMS audit records when the acuity caveat is used to explain a 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, such as the nurse’s notes?
Utah Subscriber
Answer: According to the 1995 documentation guidelines, if the history is unobtainable, the physician should state the reasons why and whatever alternate sources he or she pursued.
Using an “implied caveat” from the nurse’s notes is a gray area and not foolproof. Taken to an extreme, it would be impossible to get a history directly from a patient with active cardiopulmonary resuscitation (CPR) — 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, what sources were consulted, and thereby give the auditor no room for criticism.
Inpatient Facility Coding & Compliance Alert
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