Wiki HPI documentation

solocoder

Expert
Messages
446
Location
Marshfield, MO
Best answers
0
IF an MA interviews a patient, and notes what is essentially an HPI, and then the doctor copies and pastes that information into their note, I would not think that would count as an HPI performed by the provider. But if the provider "modifies" it with a few of his own words.... would that be acceptable?

Appreciate any help!
 
The actual HPI must be documented by the provider. They would need to clearly document that they interviewed the patient (not the MA) and obtained the HPI. Copying and pasting is not appropriate.

However they may come across similar information when they interview the patient for the HPI, so some of the information may be the same, but it would need to be distinct enough that it clearly shows the physician obtained their own HPI.
 
Copy paste of HPI

Hi Good day!

It is not at all appreciated if the HPI is copied from the previous visits basically this thing is happens in Inpatient medical records when they document H&P History and physical record they document clearly this record we have to code with initial inpatient visit with 99221 to 99223 when it comes for subsequent visits some have the crew of physician's are copied the information from the initial visit and they paste it in subsequent document, if that is the case we don't want to consider it and we need to educate the provider by conducting the provider education as well if any changes are made in HPI for sure we need to consider the document and we have to code the entire document with appropriate level.

Hope this is useful for your practice!

Thanks&Regards,
Suresh myneni CPC.
 
Top