Question E/M Progress Note - Interval History

datdatcat

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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!!
 

datdatcat

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Update...I am now being told that I can find the interval history for a subsequent encounter in the exam (and Plan) if there are any changes from the previous exam and that the initial HPI becomes part of the "medical past history" at subsequent visits!!
 

jimbo1231

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It looks like you re being given a mix of misinformation and some correct information about changes in CMS interpretation of new documentation. Despite some loosening of the rules, simply copying the HPI which is easy to do with most EMRs doesn't create any new HPI elements. However it is acceptable to copy and note any changes for that hospital visit. I think it is possible that you might find a history element in plan of care if it is clearly a history update, but I have my doubts about the PE being mixed with history since they are clearly different. Also remember with what I think are subsequent hospital visits, you only need 2/3 of History/PE/MDM for a given level. Often coding for these services is more focused on PE/MDM.

Jim S
 

sweller

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