Hpi-code for Profee and Facility


Stockton, CA
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Hope someone can and will answer this, I code for Profee and Facility side ER's we have preprinted forms so we have forms that have cc, hpi, ros, pfsh and exam on one form and then mdm and clinical impression on the 2nd form, the rest of the forms are triage and the treatment records and so on. We have been sending the chart back and asking for the dx's but we now have a new director and she is telling us that we don't have to send them back that we should be just taking from the hpi pg is she right? I just don't feel right in doing that and I have never heard that before so I need some other views on this and if she is wrong is there somewhere I can look to find it to show her? any and all help is really appreciated..alice
Are you sending the charts back for documentation or so that the physician can provide the codes? I worked for a facility that coded diagnoses from the chart notes. If your director approves it there should be no problem.
I would be questioning this practice of abstracting the the final diagnosis from the HPI. It sounds like these forms need to include a final diagnosis field. What if the documentation in the HPI is insufficient to assign a dx or it may lead to coding the symptom of a more definitive diagnosis. Please encourage your director to add this to the forms or encourage the providers to document the diagnoses under clinical impression. I really think it will raise a red flag in an audit.


I send them back because the dx is missing from the dx pg, we have pre-printed forms and have a place for the dx's which is on the MDM pg, which have a place for labs/xrays ekgs that were reviewed they have a place for if the dr needs to describe more work that he did and then a place for the dx codes and there signatures.
Thanks, alice

Sorry Susan I jumped right over your answer, we do have a place for the final dx, and it does say Clinical Impression, that is why we are questioning her on what she wants us to do, so I thought I would put the question out to see what every one else thinks/does..thank you, alice
As long as you can abstract the diagnosis from the examination then you would be fine. You cannot code with out a diagnosis obviously but if it is in the exam as to what was there, and observed then you do not need anything else. The HPI is history and the patient complaint and patient perspective/impression, and does not necessarily contain the diagnosis rendered by the provider. This will be in the body of the examination, if it is not then and there is no final impression then you have an issue. The provider does not have to supply the codes.