Lack of HPI?

dballard2004

True Blue
Messages
1,168
Location
Gower, MO
Best answers
0
Here is the scenerio:

CC: Traveling to Africa in Jan. requesting immunizations-reviwed chart-Ghana has (illegible) Malaria.

Questions: What HPI levels (if any) can we get here?

The patient has a detailed exam and low MDM. Under the history, we have 3 ROS and 1 element of PFSH. If there is no HPI in the above CC, can I determine the history level to be detailed without the HPI elements?

All insight appreciated. Thanks.
 

Lisa Bledsoe

True Blue
Messages
2,045
Location
Greeley, Colorado
Best answers
0
This really doesn't appear to be a problem oriented visit. We see a lot of patients for travel and usually code 99401-99402/V65.49 along with any immunizations/appropriate V code. The patient should sign a waiver or ABN as most insurance will not cover this.

As far as your History question, without an HPI you don't have the history key element at all.
 

dballard2004

True Blue
Messages
1,168
Location
Gower, MO
Best answers
0
Since I don't have an HPI here, I would have to base the E/M level on the exam and MDM, correct? I was under the impression that without an HPI, you could still determine your history level based on the ROS and PFSH.
 

Jagadish

Guru
Messages
155
Best answers
0
99401-99402 series is noncovered by Medicare and lot of other payors. In this scenario, as you have exam and MDM; bill it as established office visit.
 
Top