Internal Medicine Coding Alert

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. He performed a comprehensive exam and used medical decision making of high complexity, but was unable to obtain a complete history due to the patient's current condition. Can we give credit for a comprehensive history even though he couldn't obtain a comprehensive ROS (review of systems) due to the patient being mentally confused?  

South Carolina Subscriber

Answer: There is no written rule that you can automatically give credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unobtainable. In general, you can only give credit for the level of history that is documented. The viewpoint might be carrier specific, so check with your local payer.

Action: The "Documentation Guidelines for E/M Services" states, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstances which precludes obtaining a history." Accordingly, verify that your physician clearly documents the reason the patient is unable to provide a history, and document his efforts to obtain the patient's history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information from the records to document some of the history components (past medical, family, social).