Wiki What if no history obtainable for inpatient consultation?

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Bernadette10

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If no history obtainable for inpatient consultation because of language barrier, new patient, no records available, can this be coded? Exam is comprehensive, MDM high, 45 minutes spent with patient. Does it need to wait to be coded until more info can be gotten from family members if possible, or can it be coded based on the amount of time spent? It doesn't say the time was spent in counseling or coordination of care.
 
My understanding is that the physician must document that he/she was unable to obtain the history and most importantly the reason why they could not get it. The visit should be coded based on medical necessity and complexity of the visit.
 
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