HPI Question

[Tonyj]

Physician states in CC "small cell lung carcinoma, here for further therapy" Could you give credit to modifying factors in the HPI for "further therapy" knowing that chemo was the therapy given in past visits?

 

[missy874]

I only give credit to modifying factors if the provider states what the result of the factor was, either getting better, not getting better with treatment or side effects of the modifying factor.

 

[Tonyj]

I only give credit to modifying factors if the provider states what the result of the factor was, either getting better, not getting better with treatment or side effects of the modifying factor.

As per E/M coding tool for History it states "MF: factors that relieve, limit or have no effect on a symptom" That being said the MF would be included, I'm not sure if the physicians verbiage would allow me to use it.

 

[MnTwins29]

Agree with Tonyj

Without documentation as to the reason for further therapy, I would hesitate to use it for any points.

 

[Tonyj]

Without documentation as to the reason for further therapy, I would hesitate to use it for any points.

I know the reason for further therapy (chemo) which is mentioned in the A/P as "proceed with therapy". My dilemma is feeling comfortable using it as a modifying factor since it isn't mentioned specifically in the HPI.

 

[missy874]

I agree with not using it. The provider isnt stating what the effect is...in fact, he is ordering it. IF the provider said the patient was experiencing anything from past or current chemo then its a modifying factor.

 

[Tonyj]

Much thanks for your input.

 

[FTessaBartels]

E/M not allowed with Chemo

I thought you were not allowed to bill an E/M with chemotherapy (same DOS).

Not my area of expertise, so I may not be remembering this correctly ...

F Tessa Bartels, CPC, CEMC

 

[Tonyj]

I thought you were not allowed to bill an E/M with chemotherapy (same DOS).

Not my area of expertise, so I may not be remembering this correctly ...

F Tessa Bartels, CPC, CEMC

Yes, with modifier 25