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Jay
Reply with quote  #1 
A new non-Medicare patient is seen in the hospital setting as a Consult by our physician. Patient is intubated and sedated, hence a comprehensive review of systems and comprehensive physical exam are not possible (A detailed physical exam was done). The Medical Decision Making supports a Level 4 Consult (99254). Considering the fact that the patient is intubated and sedated, and that these facts are repeatedly documented in the Consult note, would the physician still be able to bill a 99254 inspite of insufficient ROS and Physical Exam?
coloradocoder

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Posts: 11
Reply with quote  #2 
I suggest contacting the payer with this question since the payers have different views on this situation.  I code for infectious disease hospital and the physicians are directed to document the reason they cannot obtain a complete history, exam, etc... When this is documented, we are instructed to give them a comprehensive level.  So, I would say as long as they are documenting the situation, you should be able to code a 99254.  However, you have to take the MDM into consideration as well to get your level.
bscott

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Posts: 100
Reply with quote  #3 
A comprehensive physical exam is certainly possible in an intubated and sedated patient. It's easier in 1995 rules, but certainly possible in 1997.

Two bullets from each of:
Constitutional (VS and general appearance)
Eyes (constricted pupils or one is blown? conjunctival icterus?)
ENMT 
Neck (midline trachea and no gross thyromegaly)
Respiratory
Cardiovascular
GI
Skin
Musculoskeletal (clubbing/cyanosis for one bullet, reasonable to check for abnormal myoclonic movements at minimum if on an opioid infusion as part of their intubation protocol...otherwise rigidity or passive range of motion aren't unreasonable)

No patient cooperation required. (Avoids the psych and neuro areas)

It may look a little funny to chart this way, but no reason to cost yourself because you felt silly writing "no gross thyromegaly" in the chart.

IF they are following the 1995 or 1997 Documentation Guidelines, then you can still get credit for the ROS if you explain why you can't get it:

From page 5 of the 1997 Documentation Guidelines:

"If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient's condition or other
circumstance which precludes obtaining a history."

I think you should have your doc amend the note. Explicitly say in that section (the ROS) that it was not obtainable because the patient was intubated and sedated. 
pjensen

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Posts: 773
Reply with quote  #4 
Unfortunately, this is a tough situation. There is a history caveat that will give full credit for unobtainable elements of history (as long as you specifically document the reason you could not get the info).  On the other hand, no such caveat exists for the exam.  This is obviously an oversight, but one that has to be dealt with.  You can either follow the advice above and somehow "grind out" the comprehensive exam, or you can shift gears and bill for critical care which does not have specific requirements for history and exam.

PJ.
Unregistered
Reply with quote  #5 
Quote:
Originally Posted by pjensen
Unfortunately, this is a tough situation. There is a history caveat that will give full credit for unobtainable elements of history (as long as you specifically document the reason you could not get the info).  On the other hand, no such caveat exists for the exam.  This is obviously an oversight, but one that has to be dealt with.  You can either follow the advice above and somehow "grind out" the comprehensive exam, or you can shift gears and bill for critical care which does not have specific requirements for history and exam.

PJ.



Can you site the ruling for this , that it applies to the history but not the exam?
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