Help with HPI points for new patient

Rebecca Pate

Networker
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39
Location
Columbus GA
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I need some help with this one.

"25 year old patient presents for initial visit. Husband is in the military and was transferred here 5/2017. She is here to establish care. She saw her GYN 2/2017 and IUD was still in place."

This is all there is in the HPI. Everything else is fine, but I have no idea how to assign points for this. Any help is appreciated!

Thanks!:confused:
 

thomas7331

True Blue
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There is no HPI here, nor is there a chief complaint. This is insufficient to establish any medical necessity to bill an evaluation and management service, unless it is a preventive care visit. I would query the provider for additional information if this is all you have to go on.
 

MikeEnos

Expert
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Location
Warwick, RI
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I need some help with this one.

"25 year old patient presents for initial visit. Husband is in the military and was transferred here 5/2017. She is here to establish care. She saw her GYN 2/2017 and IUD was still in place."

This is all there is in the HPI. Everything else is fine, but I have no idea how to assign points for this. Any help is appreciated!

Thanks!:confused:
The phrase "here to establish care" tells you that this is an annual preventive exam, not a "sick visit." There is no sufficient chief complaint or HPI to support a sick visit.
 

CodingKing

True Blue
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The phrase "here to establish care" tells you that this is an annual preventive exam, not a "sick visit." There is no sufficient chief complaint or HPI to support a sick visit.
It could also be a get acquainted visit which would not be billable at all. No way to tell without the exam information.
 
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