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General Surgery Coding Alert

Reader Question:
Other Sources May Provide History

Question: One of our surgeons admitted a 72-year-old woman as an initial inpatient. He performed a comprehensive physical examination and complex medical decision making based on the patient's current condition, but he couldn't get all of the patient's personal information because she appeared to be mentally confused. Can we count this as a comprehensive history even though the surgeon couldn't obtain a comprehensive review of systems (ROS) due to the patient's mental status?Nebraska SubscriberAnswer: There is no written rule that you can automatically give credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unobtainable due to patient condition. In general, you can only give credit for the level of history that the surgeon documents. This viewpoint might be payer specific, so check with your local payer.Tip: In many cases, however, you are allowed to count history toward the level of E/M service you [...]

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