tci ED Coding & Reimbursement Alert - 2011 Issue 11

Reader Question: (Nearly) Dead Men Tell No Tales: Apply History Exemption Caveat for Critical Care

Question: If a patient comes to the ED in critical condition and is not able to give a history, can we apply a caveat? Does that caveat also apply to physical exam or does the doctor need to perform and document a physical exam? West Virginia Subscriber Answer: If the patient qualifies for critical care, code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) does not have the typical E/M code requirements of history, physical exam, and medical decision making. As such, the typical history and physical exam required elements...

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