datdatcat
New
I am relatively new at E/M coding...I have a hospitalist who cuts & pastes his HPI from his initial H & P for his progress notes, with no updates. I questioned this and was told that he is allowed to do that. I was also told that as long as he mentions something in his Plan of Care it counts for the HPI. I was told that the Interval HPI actually refers to the PFSH! As I mentioned I am no expert E/M coder, but I didn't think any of this was true. First, I did not think that the Interval History was referring to the PFSH, but that it referred to the HPI. Also that the interval history is basically an update of the HPI since the last assessment. I'm being told that if the dr. just cuts & pastes the initial HPI then nothing changed, but how can that be if the patient was in the hospital for several days and is then discharged. I also did not think you could double dip so to speak, meaning if I'm counting something in the Plan of Care, then it should not be counted in the Interval History. I was also under the impression that cutting & pasting the HPI was a no-no. Can some one please clarify this for me? If I'm wrong so be it, lesson learned, but if I'm right, I'll also need sources/references to bring to my supervisor. Thank you for any input!!