Internal Medicine Coding Alert

Question: One of our internists noted that a patient had shortness of breath with no palpitations. The internist wrote below this that she couldn't learn anything about the patient's history because of the patient's dementia. Can I consider this a complete review of systems (ROS)?

Wisconsin Subscriber

Answer: Not yet. First, your internist must seek out the patient's medical history information from other sources, such as family members and friends. Medical history information collected from the patient's caregivers, family members or previous physicians counts toward the ROS.
 
Other way: If your internist is unable to contact any family members or previous physicians, she could claim an exception to the history requirements that addresses unconscious patients or patients who are unable to answer questions coherently. Requirement: Your internist must document all failed attempts to obtain information about the patient's history to qualify for this exception.
 
How to bill it: You can report the appropriate E/M level using 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient), but you can't bill based on time if your internist notes that the communication barrier extended her face-to-face time with the patient. Also: Most payers won't reimburse for the extra time your internist spent tracking down the patient's history from the other physicians, family members and friends.