Results 1 to 8 of 8

Exam Details used as HPI elements

  1. #1
    Smile Exam Details used as HPI elements
    Medical Coding Books
    Hello again,

    I have a dilemma. I am being told to use exam details to get credit for HPI elements to bump the consult level up. I am pretty sure I have read somewhere that you cannot do that because the exam is actual findings documented after the HPI would be documented. Can anyone help me with this and/or tell me where to find this documented?

    Thanks a bunch!

  2. #2
    Milwaukee WI
    Default HPI is NOT exam or vice versa
    The HPI is a "history" ... explained by the patient on prompting by the physician. This is SUBJECTIVE information that describes the nature of the complaint that brings the patient to the office. For example: How long has it been present? Does anything make it better or worse? How bad is it? What other symptoms go with it?

    The exam is a record of the physician's findings on examining the patient. This is OBJECTIVE information. For example: BP 120/82. The lungs are clear to auscultation. Heart is RRR w/o MRG. Abdomen is soft and tender w/o hepatosplenomegaly.

    That being said, I've seen physician's record elements of history under the "exam" heading ... so I'd have to see the actual note to tell whether you've been given accurate guidance in this particular case.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    The patient is being seen for wound rounds, they give a few things regarding this in the HPI but I am being told to use the measurements and the description (drainage color, etc) from the exam (what they observed) from the exam as HPI elements like for severity.

  4. #4
    Are you being asked to use the info for both HPI and exam?

    I agree with Tessa, and based on your example this sounds like exam to me, not HPI.

    Laura, CPC, CEMC

  5. #5
    no they want me to pull that info up to use to increase the HPI level to raise the code, it is crazy if you ask me but they will not take anything from me they have to have it in writing that you cant do that. I already used the subjective vs objective thing.

  6. #6
    Ok, next question, what kind of exam are you left with if you do pull those elements out to be used as history?

    Consults are 3 of 3, the doctors I have in infection disease that do wound care, do very limited exams. If I pulled exam elements up to beef up the history (which I am completely against since it is wrong) my level of exam would tank and it wouldn't do any good to have a higher level of history anyway.

    As far as being in writing, just give them the documentation guidelines. History is obtained from questioning the patient or other appropriate source. If the documentation states something like "3 cm wound, no purulent drainage, located on the lateral aspect of the left foot" this most likely was not obtained by questioning the patient but in fact during exam.

    It sounds like the providers need further education if their documentation is truly lacking or the powers that be need to realize what they are doing is considered fraud.

    Laura, CPC, CEMC

  7. #7
    that is EXACTLY what I am saying, they just don't listen to me this person is a NP who just went and got her CPC-P and now everything I say does not matter, I just (on saturday) took my CEMC, don't feel that great about it but did, and I am hoping that will make a difference. These NP's do SNF subsequent billing so they have other exam bullets to be able to use that is just a small slice of what they have written, and being that I am coding the encounters I do it the way I believe is right, but then get called on the carpet about it.

  8. #8
    Milwaukee WI
    Default Inpatient Subsequent Codes
    Are you talking about inpatient subsequent visit codes? 99231-99233?

    What you are looking for is an INTERVAL history ... what has happened since the last time the doctor saw the patient (yesterday, two days ago .. whenever)

    Sounds like your "advisor" wants these to be 99233 which requires 4 elements of HPI, plus 2-9 ROS reviewed, plus an interval pertinent PFSH.

    Subsequent hospital visits only need 2 out of 3 key components ... can you use MDM and exam? Of course for 99233, MDM should be HIGH ... this may or may not be the case for your actual scenario.

    While I see notes that are all jumbled up and occasionally an element of history will be at the bottom vs at the top, I still cannot double dip. As Laura said, if you took the size of the wound or color of discharge from your exam and counted it as severity, then you can't count that as part of your exam.

    Might be helpful if you could post even one of these notes as an example.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Replies: 1
    Last Post: 06-08-2012, 09:41 AM
  2. HPI elements - wants to know
    By preema in forum E/M
    Replies: 3
    Last Post: 12-19-2011, 03:36 PM
  3. Hpi elements
    By veloso in forum E/M
    Replies: 2
    Last Post: 06-28-2010, 07:15 PM
  4. How many elements are in this HPI?
    By Tammytude in forum E/M
    Replies: 14
    Last Post: 11-12-2009, 07:15 AM
  5. E/M HPI elements
    By krssy70 in forum E/M
    Replies: 4
    Last Post: 11-03-2009, 01:32 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.