Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

April 2018

Ask the Experts: How to Handle an Unobtainable Exam
For The Record
Vol. 30 No. 4 P. 10

I found the below document giving some direction on unobtainable history. But what about unobtainable exam? If a patient is admitted with pneumonia and the provider documents "unable to obtain exam due to combative patient" and they are unable to listen to the lungs and heart, would you give the same type of credit to the exam as you would to the history? Maybe not a full exam, but at least the organ systems they list this reason under. I would feel it would be necessary to listen to the patient and do a hands-on type exam vs an observational exam in order to have a proper treatment plan.

These are current internal policy at my previous place of work. Since you may not contradict Centers for Medicare & Medicaid Services (CMS) policy but only further define their policy, I feel safe in using these. What do you think, and can you cite any sources that would contradict CMS?

• If exam element states "Deferred," no credit is given for the exam.

• If exam element states "Refused" or otherwise makes it clear that the physician intended to perform the exam but the patient could not tolerate the exam because of pain or refused to cooperate due to mental or emotional issues or could not cooperate due to health issues or age, credit is given for the element. If the patient refuses the entire exam or could not be examined for some documented reason, credit can be given for comprehensive exam.

According to Noridian:

"Q6. Does a physician have to document the reason why the history of present illness (HPI), review of systems (ROS), and past/family/social history (PFSH) were unobtainable or can it be inferred by other documentation within the HPI (eg, patient intubated, had severe dementia, etc)?

If unobtainable from the patient, does a physician have to document their attempt to obtain the information from other sources (eg, family, other medical records, etc)?

If unobtainable from any source, what level of history can be assigned?

A6. Per CMS 1995/1997 Evaluation and Management guidelines, see resources: Evaluation and Management.

'If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.'"

Other MACs
The remaining Medicare Administrative Contractors (MACs) offer no further guidance on the topic of review of systems unobtainable. It is recommended that the question be submitted to the appropriate MAC for clarification. According to CMS Coding and Documentation Guidelines, it would not be appropriate to automatically assign the ROS as comprehensive when the items cannot be obtained. It is recommended that the provider obtain any information from the family, previous medical records, nursing facility, ancillary staff, ambulance staff, etc. The medical record can include an addendum when the information becomes available.

Revenue Cycle Auditor
Bend Memorial Clinic

Novitas Solutions, the MAC for the Mid-Atlantic States as well as states in Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas, addresses the scenario of the physician's inability to gather any element of the HPI, ROS, and PFSH due to patient's current clinical condition precluding the exchange of information with the patient, relevant caregivers, family members, or other individuals such as rescue squad who transported the patient. This MAC, in an available E/M Question and Answer section available on their website, reinforces the widely followed E/M guideline that the physician can receive credit for a comprehensive exam if unable to obtain due to patient's current clinical condition as follows:

Question 11 Novitas E/M FAQ
• When a physician performs an E/M service and the patient is not able to provide history, if the physician documents "patient in a coma," "patient not able to respond," "patient unresponsive," can they count a comprehensive history?

• When a physician performs an E/M service and is unable to obtain parts of the history component for that encounter, documentation should clearly reflect the components that were not obtained (HPI, ROS, and/or PFSH). Documentation should also include why the components were not obtained (patient unresponsive, sedate on a vent, etc), and attempts to obtain information from other sources, such as a family member, spouse, nurse, etc. When the Clinical Reviewers are reviewing documentation, it is reviewed in its entirety. If the documentation clearly supports that the patient is not able to provide the information necessary (history components) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited.

Now let's examine the reader's question of how to address and score the physical exam on the same patient where the history was not obtainable due to the patient's clinical condition. According to Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edition, Chapter 4, The Physical Examination (available at www.ncbi.nlm.nih.gov/books/NBK361), "Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. … Information pertinent to the physical examination can be learned from observation of speech, gestures, habits, gait, and manipulation of features and extremities. Interactions with relatives and staff are often revealing."

While parts of the physical exam require some type of interaction with the patient, there are other elements of the physical exam that may be performed without said patient interaction. E/M coding guidelines, including those published in the CMS E/M Service Guide updated in August 2017, do not speak to recording and scoring the physical exam in the face of a patient who is in a coma or otherwise is not cognizant to participate in the physical exam.

A thorough internet literature search failed to identify any specific information pertaining to performing a physical exam associated with a noncognitive patient. Given the nature of the physical exam and the fact the physician can perform some of the exam without patient participation vs history, it is logical to assume one cannot score a physical exam as comprehensive if the physician did not perform the required number of body areas or organ systems.

— Glenn Krauss is creator of Core-CDI.com.

Follow-Up Question:
This is great and very helpful, except for a scenario of a combative patient. If the provider needs to examine them for pneumonia, yes, they may be able to get a few organ systems simply from observation. However, the pertinent organ systems, pulmonary/cardiovascular, cannot be examined due to the patient being combative and that organ system not being obtainable. If this is the case, could they get credit for the organ systems they specifically list as unobtainable and the reason? If they all add up to eight, then would this be considered a comprehensive exam?

TJ Lock

I understand you are still questioning the validity and appropriateness of reporting a full 8+ exam when the patient is combative and the physician is unable to perform an exam of pertinent body areas or organ systems. While there are no official CMS guidelines that I can reference on this very issue of counting a full exam when the physician is not able to due to circumstances beyond his or her control, my personal thought from a logical standpoint is that you cannot follow the same principle governing the history portion of the H&P.

The history portion of the H&P is basically fact finding while the exam performed consists of physicians exercising their clinical judgment, skill sets, and cognitive skills. It is hard for me to imagine a payer wanting to pay for performance of a crucial element that factors into an assessment and plan of care—that is, the exam that drives generation of an assessment, whether definitive or provisional diagnoses—without the physician actually performing the exam.

I suggest you check with the MAC medical director in your region to gain his or her perspective. I am confident he or she will come to the same conclusion.

— Glenn Krauss


How do you code malignant melanoma metastatic to lungs and liver?


Without the medical record, I provided two choices for "malignant melanoma": C43.9 and Z85.820 (See below ICD-10-CM Official Guidelines FY 2018 page 33 to determine the most appropriate code for your patient).

C43.9 Malignant melanoma of skin, unspecified or Z85.820 Personal history of malignant melanoma of skin
C78.02 Secondary malignant neoplasm of left lung
C78.01 Secondary malignant neoplasm of right lung
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct

ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 33 of 117
m. Current malignancy vs personal history of malignancy
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed. When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

— Kim Riggs, RHIA, CCS, is coding integrity auditor at VitalWare.