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?
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?