tci Part B Insider - 2008 Issue 24

READER QUESTION: Look to CPT for Advice When Patient History Is Unobtainable

CPT offers definitive guidance on how to compute history for patients who can't communicateQuestion: 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...

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