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HPI Again

NESmith

Expert
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308
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I just submitted a question on this issue and I Thank You for helping me, but now my doctor is stating her HPI can come from her CC. Once again I disagree. Please help. As you can tell I am having a issue. Thanks
 

RebeccaWoodward*

True Blue
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3,126
Location
North Carolina
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The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

• Chief complaint (CC);
• History of present illness (HPI);
• Review of systems (ROS); and
• Past, family and/or social history (PFSH).

The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp
 
Messages
4,466
Location
Milwaukee WI
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Please see previous post

Please see my response on your previous post. As well as Rebecca's (as always) very helpful explanation above.

Physicians are not required to neatly label each element of their documentation (though it sure helps when they do!).

But the coder cannot double dip - counting the same verbiage for two different things.

Hope that was helpful.

F Tessa Bartels, CPC, CEMC
 
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