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Wiki E/M coding question

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Triesen1

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I have two questions.
1. If the physician does NOT document the HPI on an established patient, can we bill an E/M level? My thoughts are that you only need 2 of 3 elements to be met to bill but I am not sure.

2. For a new patient, if you list the 3 chronic conditions in the HPI and include there status is that significant enough to get a comprehensive HIP without meeting the 4 or more HPI elements. I know with an established we will meet the exam and MDM as detailed and moderate so we don't generally have to worry about that but with a new patient I was not sure. Thanks!
 
Triesen1 said:
I have two questions.
1. If the physician does NOT document the HPI on an established patient, can we bill an E/M level? My thoughts are that you only need 2 of 3 elements to be met to bill but I am not sure.

2. For a new patient, if you list the 3 chronic conditions in the HPI and include there status is that significant enough to get a comprehensive HIP without meeting the 4 or more HPI elements. I know with an established we will meet the exam and MDM as detailed and moderate so we don't generally have to worry about that but with a new patient I was not sure. Thanks!
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Question 1 - there should be an HPI because that establishes medical necessity - why is the patient there? However, for an established patient you do only need to count 2 of the 3 elements, so you could say this would be OK. It may depend on your medicare MAC, so you may want to check with them to see what they say.

Question 2 - As long as the doctor documents the status of the 3 chronic conditions you can count it as an extended HPI without having to meet the 4 or more part.

Again, a lot of this depends on your MAC and I'm sure there will be other opinions, but this is how our MAC considers these scenarios.

Hope that helps! :)
 
don't forget that, while you may not need an entire History, a chief complaint is required in order to bill a office visit, per CMS.
 
specficity of Chief Complaint question for E/M

If an establised patient comes into the office and states the only reason for their visit is for a recheck &/or follow up, does that not that constitute as an acceptable chief complaint?. Considering that the chief complaint is to be the patients words.

Thanks.
Marcie
 
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