If a patient comes in the ER with a decreased LOC an is unable to answer questions or provide any information to the Physician the level 5 caveat can be invoked for the HPI, PFSH, and ROS. Can is also be invoked for the Exam? We are getting conflicting answers and just want to see what other ER Coders do in this situation. In the specific case that prompted this question the patient was admitted and all other documentation supported a 99285.
level 5 ER Caveat for Exam?
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