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Printed Date: 9/22/2015
Per CMS guidelines, "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."
The documentation must clearly reflect:
If patient or family can provide information at a later time, the provider may add an addendum containing this information.
Resources: CMS 1995 & 1997 E/M Guidelines
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Last Updated: 07/05/2018