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Pulmonology Coding Alert

Reader Question:

Capture Two Components to Determine E/M Level When History is Unobtainable

Published on Sun Oct 28, 2012

Question: Our pulmonologist saw an initial inpatient, but couldn't get all information from him. 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?Florida SubscriberAnswer: 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, most Medicare contractors allow providers to count history toward the level of E/M service you bill if you are unable to obtain it directly from the patient. But you must document that you made an effort to obtain information [...]
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