Wiki Patient in coma

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slc112071

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I have a report on a patient for a consult/E M, but the patient is in a coma. The neurosurgeon visited the patient three times that day, but did not document the total time spent. The question is that the surgeon cannot get any type of history or review of systems from the patient and there was no family available. There was no way possible to get a valid neuro exam. The patient was declared brain dead the next morning. How would anyone code this type of visit?
 
As far as the History component, as long as your doctor documents why he could not obtain this portion and the steps he took to try and get the information, i.e. no family members available, old records not available, etc. then he can consider this portion as comprehensive. He still would need to do a comprehensive exam on the patient to qualify for the higher levels.
 
Read the patient chart

Is there no history documented in the patient chart? When dealing with a hospital patient there is no need to ask the entire ROS and PMFSH again ... but the physician MUST document that s/he reviewed the information already in the chart and point the auditor to where the information is located.

For example: I reviewed the ROS and PMFSH documented in the H&P of dd/mm/yy.

Hope that helps

F Tessa Bartels, CPC, CEMC
 
Hi Jodi, do you have a link to this information? I thought the same thing but can't prove it.
 
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