tci ED Coding & Reimbursement Alert - 2001 Issue 7

Reader Question: E/M Without Patient History

Question: How should we code E/M in the ED if we are unable to obtain a patient's history?Maine Subscriber  Answer: E/M services 99281-99285 (new or established patient) and 99291-99292 (critical care) provided in the ED require three key components: a problem-focused history; a problem-focused examination; and medical decision-making of low, moderate or high complexity. An ED physician unable to report a patient's history must document the condition and/or circumstances that precluded the history. Some patients might be too ill to speak, uncooperative or unconscious, or they're at high risk unless treated immediately. This is called "the emergency...

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