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Radiology Coding Alert

Reader Question:

Obtain History From Patient as Exception, Not Rule

Question: In the June 2004 article "ICD-9 V71.89 : It's Not a Quick Radiology ICD-9 Fix," you stated that coders can "obtain the patient's clinical history (including signs and symptoms) directly from the patient upon scheduling, reception, or during the examination ... to support the exam's medical necessity, even if the referring physician doesn't provide it." Our compliance department doesn't allow us to use information that the patient gives us directly. Does CMS publish a position on this? New York Subscriber Answer: Yes. According to CMS'Sept. 26, 2001, Program Memorandum AB-01-144, "On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician." And CMS' official 1995 E/M Guidelines states, "The ROS [review of systems] and/or PFSH [past, family, social history] may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."

Therefore, on the rare occasion when your radiologist must take the patient's clinical history directly from the patient, he should go over it with her and document that he reviewed it carefully. And you may have to verify the history with the ordering physician to ensure that the patient did not omit any critical data.

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