HPI vs PMH

slivingston

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Mechanicville, NY
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Our practice has an Endocrinologist and his is billing all of his follow up visits as 99214's. When doing the review he is lacking any history (as I see it) but a co-worker thinks we can count the review of the patients logs as PMH. When the provider documents :
His last A1C was 7.1% and I know that about two years ago he was in the high 8% range so he really has made a lot of progress:

Reviewed patients logs for the last 4 weeks and tends to be about 150 to 160 at lunch and is over 200 at supper and bedtime.

I count these either as reviewing labs or timing in the HPI, however my co-worker thinks that we could count these as PMH.

Any opinions would be greatly appreciated.
 
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Milwaukee WI
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You need a DETAILED history

So you need a DETAILED history?

To get that you need
1) 4 elements of HPI / or the status of 3 chronic conditions (if you are following 1997 guidelines, or if your carrier allows you to use this with the 1995 guidelines)

IF you have #1, .... THEN ...

2) you need at least 2 systems reviewed of the 14

IF you have #1 AND #2, .... THEN ...

3) you need at least one item of PFSH

You state he is lacking any history ...
If that is absolutely true than I don't see how you can squeeze out a detailed history from the little example you give. However ... if what you mean is that he has not documented a past medical, social or family history ....

I MIGHT be persuaded to count a statement about reviewing status of the patient's condition from 2 years ago as past medical history, though really I'd much rather count this as ROS.

A better option would be to train your physician to always include a social history - alcohol and tobacco use (or lack thereof). This is medically relevant to the patient's condition and will satisfy the documentation requirement for at least one element of PFSH. (Won't help with getting an HPI and ROS, but that's another story.)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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