• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

A&P supported in HPI

Create Wiki
B

BLapier

New
Messages
2
Location
Port Henry, NY
Best answers
0
Hello,
I have a question in regards to coding E/M levels for outpatient primary care. Do the diagnoses in the A&P need to be supported in the HPI in order to code that Dx? For example, say you have a diagnosis and plan listed in the A&P but the HPI discusses other things not related. I know you can’t code from the HPI but shouldn’t the A&P be supported in the HPI?
 
BLapier said:
Hello,
I have a question in regards to coding E/M levels for outpatient primary care. Do the diagnoses in the A&P need to be supported in the HPI in order to code that Dx? For example, say you have a diagnosis and plan listed in the A&P but the HPI discusses other things not related. I know you can’t code from the HPI but shouldn’t the A&P be supported in the HPI?
Click to expand...
I work for an Internal Medicine & Pediatrics Primary Care practice. We have had our malpractice carrier conduct chart audits for us, and their recommendation from a legal standpoint is that if the provider is prescribing meds, ordering tests, etc for a dx then that dx should be included in HPI. If dx is treated by a specialist or another provider, they recommend to indicate in the A&P that the patient follows Dr. ABC at cardiology for diagnosis. Hope this helps.
Example:
I50.22: Chronic systolic (congestive) heart failure
Patient follows Dr. Smith with Cardiology Assoc. last seen in March 2026
 
I think sometimes though, people come in and give the HPI and other things might crop up that need to be addressed/managed which appear in the exam, plan, and other parts of the note. This might not necessarily be what they presented with. Should it be there? Most times, yes. Will it always? I don't think so. The A&P could have new findings not mentioned in the HPI. My perspective. The HPI is subjective and the patient giving their story. However, if it is a chronic condition type visit, the status of each should be there. This could be quite dependent on the type of practice.

The old 95/97 references, can't be used for E/M coding, but the HPI concepts are still valid. Talks about HPI, ROS, PFSH.


The advice above is best that it be there and be detailed and complete. Especially from a risk management and MR documentation standpoint, but from a coding standpoint it's not always going to be.
 
You must log in or register to reply here.
Top