1. KStaten

    Question Who Has Documentation Permissions per Medicare Guidelines?

    Hello Everyone! :) I am trying to put a table together to describe components of a medical document for a typical outpatient setting office visit and list who (per Medicare guidelines) has permission to document each one. In other words, in order to correctly bill under the physician, what...
  2. M

    Question Which part of the documentation can Coders use to code from?

    I'm really sorry if this has been posted before but I couldn't find anything when I searched the forum (probably because I couldn't figure out how to phrase it correctly.) Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the...
  3. G

    Question CC/HPI

    I have been unable to find information regarding when CC and HPI do not have anything in common. Everything I read states the CC is a medically-necessary reason for the patient to meet with the physician and HPI should explicitly describe the chief complaint. I believe the CC is medically...
  4. N

    Question HPI in E/M Leveling

    When leveling a GI office visit where the reason for the visit is to plan a screening colonoscopy with no presenting problems, what information are we allowed to use under the HPI section of an E/M Leveling sheet? My team lead and I are trying to determine if we can use "location" since we know...
  5. D

    Question HPI Copy and Paste

    I have a Hospitalist that copies the ER provider's HPI and pastes it into their note with "Per ER MD:" as the title. Is this allowed? My gut tells me no, but I have searched all over to find a guideline that specifically states that the provider must document in their own words, but have been...
  6. C

    HPI “radiates” location or quality

    If patient states “chest pain that radiates to left arm” Would this be 2 elements Radiates= quality Left arm= location Or Radiates to left arm= location
  7. C

    HPI element “radiates” location or quality

    If patient states “chest pain that radiates to left arm” Would this be 2 elements Radiates= quality Left arm= location Or Radiates to left arm= location
  8. G

    Pulling from HPI

    Can someone give me an idea of number of elements that can be pulled form this HPI. New patient Provider wants level 4 (99204) Provider states 4. Also, I have a coworker who states we can use Indication: colon cancer screening as a Location, Does anyone know if this is correct? Chief...
  9. C

    HPI - Quality

    I am hoping someone can help clarify something for me re: the definiton of "Quality". I found the definition of quality = characteristics (examples given are: inflamed, dark, splotchy, brown) Our EMR system is counting the word "New" as a quality. (Example "the lesions are new and mild in...
  10. B

    Coding from HPI for LTC

    Hello All, I work in LTC and I got a notification from one of my MDS nurses that they had added a dx of Dementia for a resident, but I did not have it on my diagnosis sheet for that particular resident. I went through all the documentation and could not find a dx or dx code of Dementia for said...
  11. Rebecca Pate

    Help with HPI points for new patient

    I need some help with this one. "25 year old patient presents for initial visit. Husband is in the military and was transferred here 5/2017. She is here to establish care. She saw her GYN 2/2017 and IUD was still in place." This is all there is in the HPI. Everything else is fine, but I...
  12. C

    HPI Elements-This new patient

    I have the following HPI scenario: "This new patient to my practice presents today to establish me as his new primary care physician and to discuss a 2 week history of black stools. He also describes a 1 - 2 year history of progressive fatigue and shortness of breath. He denies any cough...
  13. D

    E/m auditing

    When an established patient comes in does the physician have to update their exam or can they just carry it forward from a previous visit? If they change/add one thing to the exam (one section not the whole exam) does this allow them to use the complete exam from the previous visit? On the...
  14. V

    CC versus HPI

    Hi, It is acceptable to have the NOTES of HPI in the Chief Complaint (s) line? and leave the HPI line BLANK? Thank you, IM
  15. A

    HPI multiple problems

    I have a question about HPI. When a physician documents multiple problems in HPI and you don’t really have enough in one problem can you use the other problems to get a comprehensive or do you need to pick one problem and focus on that? An example of what I’m talking about is: “Reports that...
  16. I

    ROS question for Gastrointestinal

    I work in a gastro clinic. Under the ROS for Gastrointestinal my physicians have been stating Please see HPI. Is this acceptable? Thank you.
  17. M

    Opinions on HPI please

    Hi I was wondering if anyone could tell me what elements they would pull from the following HPI. Pt has a history of bladder cancer, transitional cell, advanced initially treated with Gemzar, carbo, Taxol, and had surgery done and there was residual small cell component. She had four cycles...
  18. A


    Question - There has been some debate on two items relating to E/M coding and I would love feedback that may help me to not only educate myself but my physicians and colleagues... 1. Medical Decision Making - we utilize the 1999 Table of Risk - but there is some debate in determining what...