Tonyj
True Blue
Pt seen as an inpatient consult. Pt is intubated and sedated. Physician states "unable to obtain ROS nor Family Hx from pt. How would this be counted in the HPI?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki PFSH question
- Thread starter Tonyj
- Start date
MnTwins29
True Blue
While this doesn't directly answer your question, it may give some insight into what level of history can be assigned given the patient's conditions.
"While documentation of the CC is required for all levels, the extent of information
gathered for the remaining elements related to a patient's history is dependent upon
clinical judgment and the nature of the presenting problem."
http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf
"While documentation of the CC is required for all levels, the extent of information
gathered for the remaining elements related to a patient's history is dependent upon
clinical judgment and the nature of the presenting problem."
http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf