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Thread: Lack of HPI?

  1. #1

    Default Lack of HPI?

    AAPC: Back to School
    Here is the scenerio:

    CC: Traveling to Africa in Jan. requesting immunizations-reviwed chart-Ghana has (illegible) Malaria.

    Questions: What HPI levels (if any) can we get here?

    The patient has a detailed exam and low MDM. Under the history, we have 3 ROS and 1 element of PFSH. If there is no HPI in the above CC, can I determine the history level to be detailed without the HPI elements?

    All insight appreciated. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007
    Greeley, Colorado


    This really doesn't appear to be a problem oriented visit. We see a lot of patients for travel and usually code 99401-99402/V65.49 along with any immunizations/appropriate V code. The patient should sign a waiver or ABN as most insurance will not cover this.

    As far as your History question, without an HPI you don't have the history key element at all.

  3. #3


    Since I don't have an HPI here, I would have to base the E/M level on the exam and MDM, correct? I was under the impression that without an HPI, you could still determine your history level based on the ROS and PFSH.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  4. #4


    99401-99402 series is noncovered by Medicare and lot of other payors. In this scenario, as you have exam and MDM; bill it as established office visit.
    Jagadish, CCS-P, CPC

  5. #5


    Thanks so much to all! I appreciate the help.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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