tci Part B Insider - 2014 Issue 9

Physician Notes: Unable to Get Patient History? Follow These Tips

Plus: CMS set to deny ‘related’ claims. Nearly every physician has been there—you’re trying to get a patient’s history so you can complete your E/M documentation, but you simply can’t collect the details, either due to memory issues or medical problems that preclude the patient from sharing his history with you. Fortunately, Medicare has rules for how to handle this situation. If you’re unable to obtain the history, the documentation must reflect which components you couldn’t collect (history of present illness [HPI], review of systems [ROS] or past, family and social history...

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