decisionhealth Newsletters, Answer Books - 2007 Issue 10 (October)
Answer_Book / Physical_Examinations_Histories / _4_ways_to_count_history_when_a_patient_can’t_communicate
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Article Overview
This article covers documentation guidance for evaluating history when a patient is unable to communicate, with emphasis on E/M service reporting and the need to show efforts to obtain information from other sources. It is aimed at physicians, coders, and billing staff who work with E/M documentation in settings where history may be limited by the patient’s condition. The discussion focuses on general history components, documentation expectations, and the special considerations that can arise in emergency department encounters.
Why This Topic Matters
When a patient cannot answer questions, the record still needs to support the reported level of service. Clear documentation helps show that appropriate history-gathering efforts were made and that the encounter can be coded consistently with E/M guidelines.
What You Will Learn
- How limited patient communication affects history documentation for E/M services.
- Why documentation should show attempts to obtain history from other sources.
- What broad documentation elements are emphasized when history cannot be obtained directly.
- How emergency department encounters may be affected when history is constrained by the patient’s condition.
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Documentation specialists
Codes Discussed
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