Wiki When to code for a separate E/M with a physical

[cdr4life]

It is generally understood that when billing for an additional E&M visit with a physical exam, one must document a separate HPI.
This makes good sense when the patient presents with an additional problem during a preventative visit (i.e. diabetes, cough, etc.).
However, how does one document a separate HPI for an additional E&M, which may require further work up and evaluation, when it is a finding which is discovered during the annual exam and not one that the patient presents with?
Example: Patient presents for an annual exam and the provider discovers that the patient has a serious arrhythmia which requires further work up, imaging, labs, referral, etc.
The patient did not present with this problem, there is no HPI that can be obtained, so how does one go about billing for the additional E&M?

 

[lace659]

If the problem is found by the provider during the preventative visit and it's not something that the patient complained about when presenting for the visit and not documented in the HPI, it is not separately billable regardless if further work-up is required. This problem would be bundled in the preventative visit with the preventative exam dx code primary and the problem dx secondary.

 

[Saedron]

Just my .02

You would not necessarily need HPI to bill an additional E/M. If this is an established patient, you'd need only physical exam and MDM to quantify the level of E/M. Leave the history since there was no history when the patient presented to the office.