Primary Care Coding Alert

Question: A new patient visited our office for evaluation for an epidermoid (sebaceous) cyst excision. Although the physician documented "sebaceous cyst" in the medical assessment as the chief complaint, he didn't document ROS or a full HPI. The physician completed an expanded, problem-focused exam and medical decision making of low complexity. What should we bill for this encounter? California Subscriber Answer: Because the physician doesn't document history of present illness (HPI) for this new-patient encounter, you may not have a billable service. According to the documentation guidelines for E/M services, the physician must document the HPI portion of the history, and history requires at least one element of the HPI. Further, you need documentation of all three key components (history, exam, and medical decision making) to support a new-patient level E/M code. If you truly have no HPI documentation, you cannot submit a claim for the new patient encounter based [...]