tci E/M Coding Alert - 2014 Issue 3

Reader Question: 'Unable to Communicate' Caveat Only Applies to History

Question: I need help with the E/M for a patient with dementia. The patient took a fall and has a contusion to an elbow and to the temple area; she was unconscious when my doctor saw her in the hospital. She was unable to communicate, but there is no mention of why in the physical examination. Dementia is mentioned in the assessment. Would this be considered a comprehensive examination?Virginia Subscriber Answer: There is no Medicare guideline that states that if your physician is unable to communicate with the patient, you can assume a comprehensive examination. Regardless of whether...

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