tci ED Coding & Reimbursement Alert - 2019 Issue 7

Reader Question: How Do You Support Caveat Intent?

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 (the nurse’s notes, EMS notes, etc.)? Supercoder Subscriber Answer: According to the 1995 documentation guidelines, if the history is unobtainable, the physician should state the reasons why and whatever alternative sources he pursued. Using an “implied caveat” from the nurse’s notes is...

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