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Internal Medicine Coding Alert

You Be the Coder:

Decide E/M Level Even Without Patient History

Question: Our physician saw patient in the office, but couldn’t get all necessary information because the patient was agitated and confused. The physician performed a comprehensive exam and complex medical decision making based on the patient’s current condition. Can we give credit for a comprehensive history even though he couldn’t obtain a comprehensive ROS (review of systems) because of the patient’s mental state?

Florida Subscriber

Answer: Payer viewpoints might vary, but you generally can only give credit for the level of history that is documented during the encounter. There is no written rule stating that you can automatically give credit for a comprehensive level when all or part of a patient’s history (e.g. ROS) is unobtainable.

Tip: However, most Medicare contractors allow providers to count history toward the level of E/M service you bill if you are unable to obtain it directly from the patient. But you must document that you made an effort to obtain information about the patient from other sources (such as family members).

The “Documentation Guidelines for E/M Services” states, “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.” Accordingly, verify that your physician clearly documents the reason the patient is unable to provide a history, and documents his efforts to obtain the patient’s history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information from the records to document some of the history components (past medical, family, social).

Note: If the E/M code you wish to bill requires only two of three E/M components, you can use the physical examination and medical decision making to determine the level of service.

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