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Need E & M code for this HPI

  1. Default Need E & M code for this HPI
    Medical Coding Books
    HPI: Pt presented for screening colonoscopy.

    The rest of the H & P I comprehensive ROS, comprehensive Exam . I am trying to educate Dr circled 99203 . What can I say ?

  2. #2
    Location
    Tacoma, WA
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    Default
    Quote Originally Posted by carol52 View Post
    HPI: Pt presented for screening colonoscopy.

    The rest of the H & P I comprehensive ROS, comprehensive Exam . I am trying to educate Dr circled 99203 . What can I say ?
    Well that looks more like the Chief Complaint. There is no HPI in that statement. And was there documentation of PFSH?
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default
    Quote Originally Posted by carol52 View Post
    HPI: Pt presented for screening colonoscopy.

    The rest of the H & P I comprehensive ROS, comprehensive Exam . I am trying to educate Dr circled 99203 . What can I say ?
    This sounds to be like the "reason for the visit", no chief complaint listed here that I see and not much of an HPI in my opinion. I'd show the doctor the CPT manual the green pages and also go the the cpt code range he/she picked where it describes what is required as well.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4
    Location
    Tacoma, WA
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    1,087
    Default
    Quote Originally Posted by rthames052006 View Post
    This sounds to be like the "reason for the visit", no chief complaint listed here that I see and not much of an HPI in my opinion. I'd show the doctor the CPT manual the green pages and also go the the cpt code range he/she picked where it describes what is required as well.
    I think the "reason for the visit" and "chief complaint" are one in the same. This is what I got from the description in the CPT book anyway. But there definitely is not HPI in this documentation.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  5. Default
    I appreciate the responses , I have discussed what is needed in the HPI and he has been better I agree with your findings of CC. Thanks so much.

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default E/M is part of the colonoscopy
    If the patient came to you for a colonoscopy, the evaluation is part of the reimbursement for the procedure. You should not be billing ANY E/M separately.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. Default
    So, even though the patient was referred to the Dr (Surgeon) and had not been in the office before to discuss the c-scope you cannot bill for the E & M ?

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