E/M Documentation for 2 or more problems, help!

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I'm trying to remember if a patient comes in for a visit and has complaints of 2 or more problems, then do you combine the elements in the HPI, ROS, PFSH, exam, and MDM to obtain your final code or do you separate them?

Thanks,
Kellie
 

Chelle-Lynn

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If both problems are related to the Evaluation and Management, meaning they would not be coded to a procedure for example, then you would combing the documentation under history, exam, and MDM for an overall E&M level.

Example: Patient is seen for ear pain and rash on his leg. All of the documentation for these two conditions would be calculated for one E&M.

However, if part of that documentation is related to example 10060 for an I&D for an abscess, then you would not count the documentation for the I&D procedure when calculating your E&M code.

Please let me know if I misunderstood your question. :)
 
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Thank You!

Just to make sure I understand if someone came in with ear pain and hit 2 points for that diagnosis and then leg pain and hit 2 points for that diagnosis in the HPI then total would be 4 since we are combining the problems then?
 

Chelle-Lynn

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Depending on whether the issues are new or established:

1 point Self-Limited or Minor Problem (max 2 points)

1 point Established problem stable (max 4 points)

2 point Established problem worsening (max 4 points)

3 point New Problem no additional work up

4 point New Problem with additional work up

If the ear pain and the rash were established problems but worsening, then yes, it would be a total of 4 points.
If the ear pain and the rash were established problems that are stable it would be a total of 2 points.
etc...
 

CatchTheWind

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The AAD addressed this question in an excellent article back in 2012, which can still be found at https://www.aad.org/dw/monthly/2012/september/understanding-hpi-elements.

Assuming nothing has changed since then, if your MAC happens to be Novitas Solutions, they will allow you to count double points (ie: you can get two points for location if it's been documented for both problems). However, all other MACs will only allow you one point for each element, regardless of how many different problems it's documented on.

I don't know what the commercial carriers do, but we go on the assumption that they follow what most Medicare carriers do and only allow each element once.
 

thelton

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I must disagree with the above statement regarding Novitas allowing credit for location twice in the HPI. They have said in recent E/M webinars on using their audit sheet that an HPI element can only be counted one time. You can, however, count something in the HPI and as a ROS.
 
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