Reader Question: Don't Automatically Assign Comprehensive History

Why This Topic Matters

E/M level selection depends on what is documented, so incomplete history documentation can affect code support and compliance. The article is useful for avoiding unsupported assumptions and for understanding when additional source documentation or payer guidance may be relevant.

Article Sections

1. Question

   A reader presents a documentation scenario involving an inpatient admission and incomplete patient history. The question focuses on whether a higher level of history can be credited when the patient cannot fully participate.

2. Answer

   The response discusses general documentation expectations for E/M history and notes that payer policies may differ. It also addresses what should be documented when history cannot be obtained directly.

3. Tip

   This section describes the need to document efforts to obtain history from other sources when the patient cannot provide it directly. It emphasizes source documentation rather than automatic crediting of a higher level.

4. Action

   The article cites guidance for documenting why history is unobtainable and describes the need to record circumstances that prevent history collection. It also references using available sources to support historical components when appropriate.

5. Note

   This section explains that some services may be selected without relying on history alone and mentions an emergency department circumstance under which a higher-level visit may be considered. It places the issue in the context of the applicable E/M rules and service setting.