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Oncology & Hematology Coding Alert

Reader Question:

E/M Guidelines Offer History Insight

Published on Thu Mar 15, 2012

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. He performed a comprehensive exam and complex (high) 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? South Carolina SubscriberAnswer: In general, you can give credit only for the level of history that is documented. However, when the documentation meets certain requirements, payers may allow you to count history toward the level of E/M service you bill even if the physician is unable to obtain the history directly from the patient.What the guidelines say: Both the 1995 and 1997 "Documentation Guidelines for E/M Services" state, "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 [...]
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