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unobtainable history

Lynn Posted Fri 26th of April, 2013 02:06:46 AM

If the ROS and PFSH are unobtainable and the doctor documents the reason, can't they get credit for 10 ROS and all 3 of PFSH?

SuperCoder Answered Mon 29th of April, 2013 05:01:51 AM

Our Senior Editor is working on this. Thanks for being patient.

SuperCoder Answered Mon 29th of April, 2013 07:08:43 AM

Yes, you can give full 10 point ROS (ROS - Comp.) or 3 point PFSH (Comp.) in that case. This comes under "rule of caveat" in E/M coding. Please note that the physician must document the reason for portion of history unobtainable (Pt. unconscious/ Pt. got head trauma and in coma / Pt. has amnesia etc.). Without the reason mentioned clearly, a simple document of "Hx / or part of Hx is unobtainable" is not enough to give "Comp." credit for those part of History.

Also, in this situation you can code "Comp." only for that particular section of History (HPI, ROS, PFSH), NOT THE FULL HISTORY.

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