Neurosurgery Coding Alert

Question: The surgeon calls in for a consult at the hospital. The patient arrives intubated. Due to the patient’s present condition, we are unable to obtain a history of present illness (HPI) or review of systems (ROS). I’ve heard that this means that the provider can code the HPI and ROS as complete. Is this correct?

New York Subscriber

Answer: When a patient is ventilated, intubated, or in any other kind of state preventing the provider from obtaining an HPI or ROS, the provider can mark both HPI and ROS as complete. However, in order to code these as complete, the provider will need to document the reason that they cannot obtain an HPI or ROS. In their documentation, providers should state “unable to obtain due to (clinical condition).”

Note: The provider should document an attempt to obtain history from other sources (eg. family, EMS personnel), if available. The level of evaluation and management (E/M) service will not be limited by the history; but rather you should base this determination on the complexity of the examination and medical decision making (MDM).

The only instance in which this rule would not hold up is if the physician ends up providing any kind of critical care. In those cases, the provider will determine the correct code on the basis of time spent, the nature of the patient’s condition, and the extent of care the physician provides.