Wiki Hpi

[falconfans]

If the patient is returning for lab test results, are you able to get an HPI, if it just states here for lab results?

Thanks,

 

[dwaldman]

Are you looking at encounter where it was a return for lab results which does not meet a brief HPI?

 

[falconfans]

Yes, where the physician usually documents the HPI, it only states here for lab results...Nothing else? Thanks

 

[dwaldman]

What about the exam and the medical decision making if this is a follow up can you bill based on these two. I am just trying to picture the lay out of the office visit note that you are looking at. It sounds like Return for lab results is the chief complaint then did he document the exam and plan/comments/impression. Does it look like he covered the history in his final comments about the visit and patient?

 

[Belinda Frisch]

Return for lab results

"Return for lab results", to me, is a chief complaint. No HPI elements there: location, quality, severity, duration, etc. I'd defer to the exam and MDM when making the code selection. Most likely this is a problem-focused visit (99212) if it was done by an MD or NPP.