Wiki Lack of HPI?

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dballard2004

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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.
 
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.
 
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.
 
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.
 
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