tci ED Coding & Reimbursement Alert - 2011 Issue 1

Reader Question: Remember Documentation When Applying Caveat

Question: An apparently homeless patient presents to the ED via ambulance unresponsive with a suspected brain aneurysm. The patient, who had no identification on his person, was found by a homeless man who accompanied the patient to the ED in the ambulance. The man said that he "knew the guy a little bit; he had been complaining about his neck and bad headaches lately." The man could not, however, provide more than the patient's first name. Therefore, the physician had almost no history information; she did, however, provide a comprehensive examination and perform high-complexity medical decision making (MDM) before...

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