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Ob-Gyn Coding Alert

Reader Question:

No History? Don't Assume Comprehensive Level

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. However, he did perform a comprehensive physical examination 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) due to the patient being mentally confused?South Carolina 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. In general, you can only give credit for the level of history that is documented. This viewpoint might be payer specific, so check with your local payer.Tip: However, in many cases you are allowed to count history toward the level of E/M service you bill even if you are unable to obtain it directly from the patient. But you must document that [...]

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