Gastroenterology Coding Alert

Question: A new patient visits the physician with a chief complaint. I don’t have a review of system (ROS) or full history because the doctor didn’t document a history of present illness (HPI). He did include a brief HPI in the medical assessment that I credited toward the chief complaint. The physician completed an extended, problem-focused exam and medical decision making of low complexity. Can we bill for this encounter? Minnesota Subscriber Answer: According to guidelines, the physician must document the HPI and the exam (with the exception being vitals, which a nurse or PA can document). You need documentation of all three key components (history, exam, and medical decision making) to support a new patient level E/M code. The documentation guidelines for E/M services also state that the chief complaint, ROS and past/family/social history, may be listed as separate elements of history, or they may be included in the [...]