Medicare Compliance & Reimbursement

Question: Our physician admitted someone as an initial inpatient, but couldn’t get all her information. However, he did perform a comprehensive physical examination and complex medical decision making based on 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?

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. This viewpoint might be payer specific, so check with your local payer.

Tip: However, in many cases you are allowed to count history toward the level of E/M service you bill even if you are unable to obtain it directly from the patient. But you must document that you made an effort to obtain information about the patient from other sources.

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 historical components (past medical, family, social).

Note: In certain cases you shouldn’t use history to select your code. If the E/M code you wish to bill requires only two of three E/M components, use the physical examination and medical decision making to determine the level of service. If the comprehensive service takes place in an emergency room, code 99285 (Emergency department visit for the evaluation and management of a patient ...) because the definition of this CPT^® code includes the exception “within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status.”

So accordingly, if you have indicated that you sought information from all available sources, and your service requires a comprehensive history, and you have performed a comprehensive physical examination and a complex medical decision making, you may bill the comprehensive visit according to the guidelines of the specific payer.