Wiki unable to obtain history of present illness??

[LouiseR1]

When billing a hospital admit code, if MD notes that he is unable to obtain additional info, pt transferred to er from Nursing Home, EMS had been called sent to ER. Patient with Lethargy and tachycardia. in ER SVT @220 found to be dry.
past medical history as from previous admissions, but MD did note.

can I still bill even though the HPI is lacking because he cannot obtain any history from Patient? ALL other elements are present---

Help is appreciated

thanks,
Louise CPC

 

[twizzle]

When billing a hospital admit code, if MD notes that he is unable to obtain additional info, pt transferred to er from Nursing Home, EMS had been called sent to ER. Patient with Lethargy and tachycardia. in ER SVT @220 found to be dry.
past medical history as from previous admissions, but MD did note.

can I still bill even though the HPI is lacking because he cannot obtain any history from Patient? ALL other elements are present---

Help is appreciated

thanks,
Louise CPC

He needs to say exactly why he couldn't obtain a history(dementia/whatever) and he needs to back it up by saying there were no family members or nursing staff available to help with the history if this was the case. In other words, if he doesn't go out of his way to try to obtain a history, he cannot get credit.

 

[LouiseR1]

what if the subsequent note the very next day lists
"patient with history of dementia/parkinsons and no family members have been present thus far"

would that suffice? if not, can he ammend the note to include that entry since listed on a seperate day?

Louise CPC