Wiki Hospital Admission E & M

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sparks

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Does anyone know the recommendations/guidelines/penalties for a Hospital Admission E & M or H&P that is missing a key element? This could be either because the patient is non compos mentis or uncooperative or the physician simply neglected to write down/list the ROS, for example.

Thank you so much!-Sherri
 
I currently review all the admissions, discharge summaries, subsequent visits, consults and critical care for the Hospitalist group where I work. A review of systems must be dictated in order to bill any admission. If the patient isn't cooperative or is unconscious all that needs to be dictated is "Review of Systems unobtainable due to the patients dementia", for example.That is acceptable. Another thing I've noticed is the doctors dictating that the family history or social history is uncontributory, that means they didn't ask the patient. They can state that after reviewing the family history, theres nothing pertinent to the current issue.
I hope this helps.
 
Depends on who the carrier is

WPS Medicare will not allow for an automatic level based on the provider being unable to obtain the info from the patient directly. If you do not have all the required elements to support an initial, you drop down to the subsequent care levels. If you do not have enough for those, you use the unlisted 99499.

The official guidelines state providers should document why they were unable to obtain whatever it is they couldn't get. They do not state you can count that documentation as meeting the leveling requirements.

Some carriers may allow that, others do not. Be sure what your carrier will accept before automatically giving credit for missing or unobtainable information.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 
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