HPI Documentation vs. time stamp

hollys

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Hello-
I'm wondering if anyone has reviewed documentation that states that the patient has no complaints, then contains a complete exam and is finished off with a time stamp. Does the time override the HPI?
Thanks-always appreciate different views and feedback!
H. Scheaffer, CPC, CPMA, CEMC
 

hollys

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There is only a brief mention of a problem that is not found on exam, but mentioned briefly in the summary- the patient is presenting with no complaints. I see this as more of a physical, since there are minimal problems, but will run into an issue because of the time stamp.
HS
 

Chelle-Lynn

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If the time is documented correctly such as "45 minutes spent with the patient and 30 minutes was spent counseling regarding changes in medications" then it would be appropriate to code based on the time documentation.
 
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