1. KStaten

    Documentation Requirements for Components of E/M

    Hello Everyone! With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends...
  2. 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...
  3. 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...
  4. 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...
  5. 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...
  6. 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...
  7. 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
  8. 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
  9. 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...
  10. 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...
  11. 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...
  12. 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...
  13. 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...
  14. 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...
  15. 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
  16. 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...
  17. 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.
  18. 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...
  19. 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...