General Surgery Coding Alert - 2014 Issue 3
Reader Question: 'Unable to Communicate' Caveat Only Applies to History
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Article Overview
This reader Q&A explains documentation considerations for evaluation and management encounters when a patient cannot communicate, particularly in the context of dementia or similar circumstances. It focuses on how history documentation may be supported, what general Medicare-related guidance says, and how payer policies and documentation examples can affect review of the encounter. The article is relevant to physicians, coders, and billing staff who need to understand broad E/M documentation expectations and payer-specific history requirements.
Why This Topic Matters
Accurate E/M documentation can affect the reported level of service and how claims are reviewed by payers. This article helps readers understand the distinction between history documentation and the physical examination when a patient cannot participate in the encounter.
Article Sections
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Question
Introduces a reader scenario involving a patient encounter where communication and documentation questions arise in an E/M setting.
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Answer
Summarizes general guidance on documentation expectations for the exam and history portions of the encounter, including references to payer policy considerations.
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Example
Provides an example of a payer’s published guidance on documenting when history cannot be obtained and the types of source information that may support the record.
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Example 2
Provides another payer example describing documentation expectations when the patient cannot provide history and when information may be gathered from other sources.
What You Will Learn
- How documentation is discussed when a patient cannot provide a history
- How payer policies may address inability to obtain history elements
- Why exam documentation and history documentation are treated differently in this context
- Which types of organizations may publish guidance relevant to E/M record support
Who Should Read This
- Physicians
- Medical coders
- Medical billers
- Revenue cycle staff
- Compliance staff
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