Wiki No HPI

[mmhubb]

I code for a pediatric office. Sometimes the pediatrician will leave the HPI section blank; there is a cheif complaint but no explanation other than the nursea quick notation of what the patient's parents may have told her the concerns are. Can I use this as part of the HPI? Should I drop the LOS due to lack of documentation.

 

[mitchellde]

HPI must be documented by the physician. If it is absent and an established patient then you can evaluate the encounter based on exam and MDM.

 

[mmhubb]

Thanks!!