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Wiki Elements of HPI

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ch81059

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Ethel, LA
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I was wondering if you could use "self ambulatory around nursing home" as severity in HPI? I don't really have any other HPI elements. Also, can hypothyroidism be used as location?
 
I have a similar issue with no HPI, but in my case this is a new patient, to establish care, with no specific concerns. New Pt requires 3/3 Key Components, one of which is History that requires 3/3 HPI,PFSH and ROS...how does one determine level of Hx w/o HPI?

Any thoughts anyone?
 
For ch81059- would need to know chief complaint
for ljgcpcaz- if there is no complaint, there is no diagnosis. Without a diagnosis there is no medical necessity for the visit. You could bill a well visit if pfsh and ros is complete and exam is done. Lburke
 
@ch81059 - self-ambulatory is more of a musculoskeletal review of systems. It would be a stretch to count it as HPI-severity unless the physician is specifically evaluating their gait.

@ljgcpcAZ - sounds like a routine preventive visit, not a new patient office visit. If it's a child use V20.2 and if it's an adult use V70.0 and bill it depending on the patient's age 99381- 99387
 
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