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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Article Overview
This article explains documentation guidance for evaluation and management services in situations where history is unavailable due to the patient’s condition. It is aimed at physicians, coders, and compliance staff who need to understand how the AMA discussed documenting the circumstances that prevent obtaining a history or performing a full examination. The piece is a short Coding Consultation Q&A and focuses on general documentation expectations rather than code lists or detailed examples.
Why This Topic Matters
Accurate documentation can affect whether an evaluation and management service is supported in the record when a patient is unresponsive or otherwise unable to provide history. This article is useful for readers who need to understand the AMA’s documentation perspective for these special circumstances.
Article Sections
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Coding Consultation
Introduces the coding question and the general documentation issue being discussed for evaluation and management services.
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AMA Comment
Summarizes the AMA’s response on documenting circumstances that prevent obtaining history or completing a comprehensive examination.
What You Will Learn
- The documentation issue addressed when patient history is unavailable
- How the AMA framed documentation expectations for special patient circumstances
- The general focus of evaluation and management documentation guidance in this Q&A
- How the article fits within CPT Assistant-style coding consultation content
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance staff
- Health information management professionals
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