AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, E/M Documentation When History Is Not Available (Q&A) (January 1998)

January 1998 page 10e Coding Consultation Documentation Guidelines, E/M Documentation When History Is Not Available (Q&A) Documenting E/M services and unresponsive and comatose patients. If the physician cannot obtain the history due to the patient's condition but does a comprehensive exam and the medical decision making is of high complexity, is this reported as a level three or not, since the history was not obtained (even though the reason he couldn't perform the history is documented)? AMA Comment In those circumstances when the patient's nature of illness/injury does not lend itself to eliciting a history nor is it...

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