Need help with HPI for and E/M visit

carriganm

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I am currently coding for a family practice clinic and need some expertise for one of my providers. My provider is constantly just putting the patient's lab results in the HPI and I need to know if I am allowed to count the lab results as the status of 3 chronic conditions? I gave an example of a chart that I am currently working on. Any advise would be greatly appreciated. Thank you. :)

Pt presents today in f/up on labs. She is feeling super stressed, but otherwise fine.
Discussed labs:
CBC: wnl
CMP: wnl
Lipids: 249/74/80/154
TSH: 5.46 H
fT4: 1.41
fT3: 3.5
 

mhstrauss

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I am currently coding for a family practice clinic and need some expertise for one of my providers. My provider is constantly just putting the patient's lab results in the HPI and I need to know if I am allowed to count the lab results as the status of 3 chronic conditions? I gave an example of a chart that I am currently working on. Any advise would be greatly appreciated. Thank you. :)

Pt presents today in f/up on labs. She is feeling super stressed, but otherwise fine.
Discussed labs:
CBC: wnl
CMP: wnl
Lipids: 249/74/80/154
TSH: 5.46 H
fT4: 1.41
fT3: 3.5

IMO, no, that isn't sufficient, because in order to determine the status of the condition, the coder would have to interpret the lab results, which is definitely out of the scope of what a coder should be doing. Also, the condition itself isn't named.
 

carriganm

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IMO, no, that isn't sufficient, because in order to determine the status of the condition, the coder would have to interpret the lab results, which is definitely out of the scope of what a coder should be doing. Also, the condition itself isn't named.

That is kind of what I was thinking too. Some of my co workers think otherwise which I why I wanted to ask some one else's opinion. The only thing that I thought it had going was she noted that the CBC and CMP were WNL (within normal limits) and the the TSH (thyroid) is H (high). And the status I think in the providers mind is the result itself. But I just don't know in an auditing situation how it would be interpreted.
 

mhstrauss

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That is kind of what I was thinking too. Some of my co workers think otherwise which I why I wanted to ask some one else's opinion. The only thing that I thought it had going was she noted that the CBC and CMP were WNL (within normal limits) and the the TSH (thyroid) is H (high). And the status I think in the providers mind is the result itself. But I just don't know in an auditing situation how it would be interpreted.


Even with the "WNL" taken into consideration as being stable, the provider still doesn't state the condition being monitored. Have you looked for examples of proper documentation for this?
 

carriganm

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Even with the "WNL" taken into consideration as being stable, the provider still doesn't state the condition being monitored. Have you looked for examples of proper documentation for this?

I have tried and I can not seem to find an answer anywhere.
 

mhstrauss

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I have tried and I can not seem to find an answer anywhere.

There's a lot that comes up if you google "status of 3 chronic conditions". But as far as required documentation, this FAQ from WPS is about the closest thing I could find...see #7.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml

Or #6 here:

http://www.novitas-solutions.com/we....ctrl-state=14i1bu3lov_84&contentId=00005056#!

Your MAC may have similar guidance.

HTH some!
 

carriganm

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There's a lot that comes up if you google "status of 3 chronic conditions". But as far as required documentation, this FAQ from WPS is about the closest thing I could find...see #7.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml

Or #6 here:

http://www.novitas-solutions.com/we....ctrl-state=14i1bu3lov_84&contentId=00005056#!

Your MAC may have similar guidance.

HTH some!

Thank you for all of your help! I really appreciate it. :)
 
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