decisionhealth Newsletters, Part B News - 2015 Issue 4 (April)
No history, no problem if patient is unresponsive — but document it
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Article Overview
This article explains how to think about history and review-of-systems documentation when a patient is unable to respond because of intubation, unconsciousness, or similar circumstances. It compares office and emergency department situations, references Medicare documentation guidance and CMS site-of-service limitations, and is aimed at coders, billers, and clinicians who document evaluation and management services.
Why This Topic Matters
Accurate documentation in these scenarios affects whether evaluation and management services can be supported at the intended level and in the correct setting. The article helps readers understand the broad documentation principles that apply when normal patient history cannot be obtained.
What You Will Learn
- How unavailable patient history and review of systems are discussed in evaluation and management documentation
- How office and emergency department settings differ in this context
- What kinds of supporting documentation are generally emphasized when the patient cannot respond
- How Medicare documentation guidance is referenced in relation to incomplete history gathering
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Emergency medicine clinicians
- Practice managers
Codes Discussed
Code Ranges Discussed
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