Wiki Coding history on subsequent IP Consults

[wynonna]

When counting points under HPI-History of present Illness) do we count points from interim history only on a consult?
Or do we count HPI from points in initial visit/H&P which is usually copy/pasted to subsequent visits and consults?
thank you

 

[Orthocoderpgu]

These are subsequent inpatient visits, not consultations. Your subsequent visits (99231, 99232, 99233), the HPI is usually minimal since the patient is in the middle of active treatment. So out of the three key components the HPI was usually the lowest of the three so the coding would usually be based on exam and MDM or that was my experience. On subsequent visits the documentation needs to reflect how the patient is doing such as improving, not improving or how well the patient is tolerating any treatment. Anything documented on a previous date would not be relevant for the patient's medical condition today. And with treatment it should be improving. I coded these when the doctors had to hand write out all the daily visits. Copy/paste was not an issue then.

 

[wynonna]

Thank you! We are ENT so we were called in for epistaxis. We generally bill New pt outpatient office visits or Consults for IP less than 72 hours, such as in Observation. IP initial and Subsequent we bill for IP admissions of 3 days or more (72 hours at least)
I agree with you on HPI.
Thank you again