tci ED Coding & Reimbursement Alert - 2013 Issue 2

Reader Question: Don't Be Cavalier About Invoking The Caveat

Question: How does CMS audit records when the acuity caveat is used to explain the ED physician’s inability to obtain information? Specifically, does the physician have to write a note that states, "Unable to obtain info due to...no other source available." Or does the auditor consider the entire medical record (nurse’s notes, EMS s notes, etc.)? Utah Subscriber Answer: According to the 95 documentation guidelines, if the history is unobtainable, the physician should state the reasons why and whatever alternate sources he or she pursued. Using an "implied caveat" from the nurse’s notes...

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