Wiki Decreased Mental Status

[Chelsea1]

Our Dr. saw a pt in the hospital because of CHF. The patient was found to have increased confusion, decreased responsiveness and therefore was sent to the hospital. Our doctor was unable to get any history from the patient due to decrease in mental status. The history was obtained entirely from the chart. Due to above, can I code this as a comprehensive and if so, where would I be able to find this information to clarify this alittle more.
Thank You!!!!!

 

[sivagurulingam]

The DG of E/M state that, DG: 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 circumstance that precludes obtaining a history.
I am not able to find the information to consider a comprehensive history.
FYI : when i code the EM, my auditor says, consider complete history in this situation

 

[Chelsea1]

Thank You!!!!!