Wiki HPI Missing

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irma011

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If an encounter is missing an HPI, is the provider able to add an addendum for the HPI once the chart is locked? I personally don't think this is acceptable but upper management refuses to write off encounters as "nonbillable" due to missing HPI. The HPI is a necessity in the record in order to code an E/M code, however, i have some providers that lock their charts and don't add the HPI prior to. My understanding is once the chart is locked, it cannot be unlocked for any reason & only addendums can be added. However, i am unsure if an addendum with HPI is acceptable. Can someone provide me with some input?
 
Is there a CC? From what is there can you easily tell why the patient is being seen/treated? The HPI is part of the ROS which is no longer required for E/M leveling so I'm not sure why you are stating that without HPI elements that the encounter is non-billable. Electronic charts can be unlocked when necessary, but it should not be a normal part of business especially when adding an addendum can be done.
 
I'm not sure why you would want your providers not to get paid for their services because they forgot to document the HPI. If our providers forget an element of documentation by mistake, I send them a message asking them to add it in. They document they are amending the chart because they forgot whatever element. With that being said, with the 2021 changes this shouldn't even be a problem since E&M codes are based on either time or MDM.
 
Orthocoderpgu said:
Is there a CC? From what is there can you easily tell why the patient is being seen/treated? The HPI is part of the ROS which is no longer required for E/M leveling so I'm not sure why you are stating that without HPI elements that the encounter is non-billable. Electronic charts can be unlocked when necessary, but it should not be a normal part of business especially when adding an addendum can be done.
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There is a chief complaint, however it is not detailed. My understanding is the HPI Elements are no longer required to achieve an E/M code, however, an HPI MUST still be present addressing the patient's chief complaint(s).
 
thranowski said:
I'm not sure why you would want your providers not to get paid for their services because they forgot to document the HPI. If our providers forget an element of documentation by mistake, I send them a message asking them to add it in. They document they are amending the chart because they forgot whatever element. With that being said, with the 2021 changes this shouldn't even be a problem since E&M codes are based on either time or MDM.
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Agreed, but if there is no HPI than how can you say the problems are being addressed? If we do not have a brief description as to why the patient is here and just run a panel of labs, that doesn't support medical necessity nor tell me exactly why the patient is here.
 
irma011 said:
Agreed, but if there is no HPI than how can you say the problems are being addressed? If we do not have a brief description as to why the patient is here and just run a panel of labs, that doesn't support medical necessity nor tell me exactly why the patient is here.
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I would just send it back for them to correct documentation. Generally I just send a note that says "missing HPI, please add," or "forgot to document plan, please add." But I don't get push back from my providers here. Also if they document time they obviously have to justify it, and I added a bunch of checkboxes to our EMR that makes it easy for them "time spent included past medical records review, time spent included reviewing results with patient" etc.

If you get audited then the documentation they provide isn't going to fly with the insurance company. I don't see an issue with amending charts, but as the other user said, it shouldn't be common practice. Maybe there is some kind of handout or something you can send the providers on what is required per insurance standards? I would think on the individual insurance websites they would have some kind of education for providers.

Here is a tool I use sometimes, maybe your upper management can have a look and see what's required: https://medicare.fcso.com/SharedTools/faces/EMWorksheet_en.jspx?lob=&state=
 
If you look at the new guidelines it states that "office...services include a medically appropriate history.., when performed". So it's not 100% necessary to have an HPI. But having said that, I think the documentation should support the MDM which may include the status of the medical condition since the last visit.
 
thranowski said:
I would just send it back for them to correct documentation. Generally I just send a note that says "missing HPI, please add," or "forgot to document plan, please add." But I don't get push back from my providers here. Also if they document time they obviously have to justify it, and I added a bunch of checkboxes to our EMR that makes it easy for them "time spent included past medical records review, time spent included reviewing results with patient" etc.

If you get audited then the documentation they provide isn't going to fly with the insurance company. I don't see an issue with amending charts, but as the other user said, it shouldn't be common practice. Maybe there is some kind of handout or something you can send the providers on what is required per insurance standards? I would think on the individual insurance websites they would have some kind of education for providers.

Here is a tool I use sometimes, maybe your upper management can have a look and see what's required: https://medicare.fcso.com/SharedTools/faces/EMWorksheet_en.jspx?lob=&state=
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That seems to be an issue here, it is something i have preached about a year ago & they are still frequently not adding it. We were unlocking charts but put a stop to that because it affects the integrity of the medical record. I have provided education training quarterly and it is frustrating because the same mistakes continue to occur & i'm not sure on what else to do or what is acceptable/unacceptable. This is why i was asking if an HPI in the form of an addendum is acceptable or not seeing that this information should be one of the primary things to be entered in the chart.
 
Orthocoderpgu said:
If you look at the new guidelines it states that "office...services include a medically appropriate history.., when performed". So it's not 100% necessary to have an HPI. But having said that, I think the documentation should support the MDM which may include the status of the medical condition since the last visit.
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i agree & if they don't give me the status of the condition or don't address it, then what exactly am i to work with? How would i even select an MDM if no condition is provided? Do you see my frustration? ..lol
 
irma011 said:
That seems to be an issue here, it is something i have preached about a year ago & they are still frequently not adding it. We were unlocking charts but put a stop to that because it affects the integrity of the medical record. I have provided education training quarterly and it is frustrating because the same mistakes continue to occur & i'm not sure on what else to do or what is acceptable/unacceptable. This is why i was asking if an HPI in the form of an addendum is acceptable or not seeing that this information should be one of the primary things to be entered in the chart.
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I wish I knew what to tell you. If they get audited and it leads to not only recoupments but also fines, they're going to be extremely regretful.
 
thranowski said:
I wish I knew what to tell you. If they get audited and it leads to not only recoupments but also fines, they're going to be extremely regretful.
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Thank you, i appreciate all of your input! :) i have been telling them this will be a huge issue if an outside auditor finds these issues. At the end of the day i'm not willing to go to jail for them so i guess i will just keep doing what i think is ethically correct.
 
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