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Practice Management Alert

Reader Questions:

No History? Don't Assume Comprehensive Level

Published on Thu Jan 19, 2012

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. He performed a comprehensive exam 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? 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 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 [...]
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