Rebecca Pate
Networker
For an established patient, if you have a Detailed Exam and Moderate MDM, do all diagnoses treated need to in the HPI as well?
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Wiki Documentation requirements for Established Patient
- Thread starter Rebecca Pate
- Start date
Orthocoderpgu
True Blue
Forget the Exam and MDM. Should a medical condition being "treated" need to be in the HPI? Well, define "treated". As a general rule yes because the physician should be finding out about it currently. However, this is beyond a coders skill, there are times when a medical condition could be affecting the treatment of another medical condition. In this situation it is proper to put down in the medical condition in the assessment. So there are times when the medical conditions would not be in the HPI but is listed in the assessment since it is so closely tied to another medical condition. I hope I am making sense.
Rebecca Pate
Networker
You are. Thanks!
Rebecca Pate
Networker
I take that back. I got dinged on an audit because "the provider did not tie the HPI and A&P together. Auditor said he can't bill for something in the A&P if it isn't addressed in the HPI, for continuity or something. It doesn't make sense to me, but I am having to query him and have him correct. Is anyone else doing this?
Orthocoderpgu
True Blue
Who's the "auditor"? Someone in your office, clinic, company? or someone at the insurance company? If your clinic or company requires you to tie HPI and assessment together, that is not a bad thing. In ICD.9 days you could not bill diabetic neuropathy unless the physician "linked" the neuropathy as being caused by the diabetes. In ICD.10 that changed. The physician no longer needs to make that link. It's built into ICD.10 that there is a definite link between neuropathy and diabetes even though it may not be mentioned by the provider. Without more detailed information you may be dealing with an internal policy at your work or something similar. I have been doing this for 20+ years and never had someone tell me that the HPI & Assessment must be linked. It's not a bad idea, but it also does not take into account that medical conditions are related and can cause complications and the physician is given credit for that part of MDM because the physician cannot "un-link" the medical conditions. This is very common especially with prescription changes where a prescription is being changed for one medical condition, but it could also affect another due to the linked pathology. I would not take being "dinged" on your audit personally, it seems like your dealing more with an internal policy.