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E/M HPI elements

  1. #1
    Default E/M HPI elements
    Medical Coding Books
    For a F/U visit following a surgery for a medical oncologist that the global period does not apply:

    For the HPI, if the record states that pt is improving, no other complaints...Which element would you give credit for??

    Thanks,
    Kristen - CPC

  2. #2
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    Need more info, if all that is said is what you posted I wouldn't give credit for anything.

    Laura, CPC, CEMC

  3. #3
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    I agree with Laura, why would the global not apply? and other questions.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    The period does not apply to medical oncoligists because they are not the surgeon. They are billing the same diag, but the global does not apply to them. Keep in mind, they are MEDICAL oncolgists. They handle ALL Cancers for all specialties. ex: the surgeon does the surgery and referrs the patient to our medical oncologist. Our doctor will bill for the follow up visit with no modifier and it will get paid.
    As for the documentation in the HPI... cc: infiltrating ductal cancer of the left breast, hormone receptors.

    History: Pt returns for follow up from her mastectomy in September 2009.
    She is doing well. No complaints

    ROS: All other systems are negative.

    Physical Exam: Full Exam documented.

    Impression: NED
    Plan: She will continue in active follow up. I will see her again in six months. A total of 20 minutes were spent with patient on this encounter.
    Kristen Richard, CPC

  5. #5
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    On that one, if there is no other chief complaint I would score it like this,

    History: Pt returns for follow up from her mastectomy chief complaint,in September 2009 duration.
    She is doing well. No complaints, I don't like how this ROS is done at all and would not give credit for a comphrensive ROS even though they have the all others negative comment. I would only give credit for one but since you have no PFSH it wouldn't matter since you can't get any higher than EPF anyway.
    ROS: All other systems are negative.

    Physical Exam: Full Exam documented. Have no idea what this would support

    Impression: NED 1 Dx point Which is going to keep you at Straight Forward on MDMPlan: She will continue in active follow up. I will see her again in six months. A total of 20 minutes were spent with patient on this encounter. If % of time counseling and coordinating was documented as greater than 50% this would be a 99213, since it is not I would code this as a 99212 based on not knowing the exam level. If the exam is EPF or higher it could support a 99213.

    Just my take on it,

    Laura, CPC, CEMC

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