Wiki Chart auditing question

[Deb Pugh]

I did a chart audit on one of our providers and she didn't have any elements in her HPI. She justified her E/M level saying "If you will look at the assessments/Problems sections you will find a more than adequate ROS and HPI documentation to meet a level 4 visit code for an established patient." Is that correct? I'm not quite sure how to reply. Please help.

 

[dclark7]

An established patient only needs two out of three components, so if her Exam and MDM meet or exceed the requirements for a level 4 visit then you don't need to worry about the HPI. She does need to document a chief complaint. Also, some doctors don't document nice and neat to make it easy for us to audit, many times you haave to read through the whole note to dig out what you need and your ROS may not be in the history where you want it. Since I haven't read the note I cannot really say much, just letting you know what I've seen over the years.

 

[penguins11]

The doctor can meet criteria for the ROS for a follow up patient if the patient has filled out a new patient packet and the doctor states that they reviewed the new patient questionaire dated mm/dd/yyyy, makes note of any changes and signs and dates the questionnaire every time.