tci Medicare Compliance & Reimbursement - 2008 Issue 26

Reader Question: Look To CPT For Advice When Patient History Is Unobtainable

CPT offers definitive guidance on computing history for patients who can't communicate. Question: Our physician had to intubate a patient who was unconscious. Which level history can the physician report? Answer: When a patient is unable to communicate, you may consider the history at a comprehensive level, according to CPT guidelines. The physician's documentation should include a statement indicating, for example, "history incomplete due to patient's condition" or "unable to obtain history because patient is unconscious." The examination should include consistent findings that would demonstrate the patient's inability to communicate with you or your staff. Make sure to...

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