tci Part B Insider - 2012 Issue 13

Reader Question: Avoid Assumptions When History Is Undocumented

Question: Our physician admitted someone as an initial inpatient, but couldn't get all her information. However, he did perform a comprehensive physical examination and complex medical decision making based on the patient's current condition. Can we give credit for a comprehensive history even though he couldn't obtain a comprehensive ROS (review of systems) due to the patient being mentally confused? Answer: There is no written rule that you can automatically give credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unobtainable. In general, you can only give credit for the level...

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