Wiki Hpi

[NESmith]

One of the doctors in our practice is billing E/M visits without a HPI. She states that the active problem or assessment can be used as a HPI. I disagree Please advise Thanks

 

[jwestfall]

You are correct, first of all the HPI has to be documented by the provider. The active problems list really doesn't come in to play and can be documented by the nurse or MA.

Jennifer Westfall, RHIT, CPC, CGSC

 

[NESmith]

Thank You

 

[FTessaBartels]

Just a minute

Assuming that everything is, in fact, documented by the physician ...

Of course you could count the problem list as HPI - or ROS - or Past Med Hx.

Many physicians lump everything together in one great paragraph without neatly labeling anything, and the coder has to figure out what to count where.

If the physician has, in fact, documented everything him/herself then, yes, you could count the active problem list.

However ... I would remind my physician that you cannot double dip. So if you are going to count that problem list as history ... you can't count it for the problems to determine MDM. Maybe that will help the physician be a better documenter.

Hope that helps.

F Tessa Bartels, CPC, CEMC