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Gainingknowledgedaily

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Wondering-:confused: I have a physician who did not document enough HPI relate to his CC. So I sent him a feedback in regards to this and he says that his HPI is in his A/P section. Can I use this? I have looked in the CPT book and CMS site and I cannot find anything stating otherwise. Does anyone have any thoughts and references? Generally the HPI should be in patients own words, but in this case it is in A/P so I do not know if I can still use this.
Provider currently has
CC: tired
down in in his consult note he has ...

"ASSESSMENT/PLAN: PLAN:

Hyperglycemia: NO history of DM. On 0.6units/hr now. Will transition of insulin SS. Will not need subacute protocol. Doubt he will need lantus. May try non-diabetic diet initially."
 
This is not HPI, it is an A&P.

The HPI is information they get before they do anything and in the case of chronic conditions it should be in the patients own words.

I would not give any HPI credit for the above statements.

Laura, CPC, CEMC
 
Specifically

Specifically with this note, I agree with Laura ... this is not HPI.

However, in general ... I know physicians who dictate one long paragraph and the three key elements are mixed up in there. So just because it's not at the top of the note, doesn't mean it's not part of HPI.

For this patient with a complaint of tired I want to know something like:
Patient has felt this way for 2 weeks, seems worse in late afternoon. Even a good night sleep doesn't help.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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