Wiki Help with HPI points for new patient

[Rebecca Pate]

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!

 

[thomas7331]

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.

 

[Rebecca Pate]

Thanks Thomas! That's what I was thinking, just wanted a "2nd opinion".

 

[MikeEnos]

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!

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]

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.