# Help with HPI points for new patient



## Rebecca Pate (Jun 12, 2017)

I need some help with this one.

"25 year old patient presents for initial visit.  Husband is in the military and was transferred here 5/2017.  She is here to establish care.  She saw her GYN 2/2017 and IUD was still in place."

This is all there is in the HPI.  Everything else is fine, but I have no idea how to assign points for this.  Any help is appreciated!

Thanks!


----------



## thomas7331 (Jun 12, 2017)

There is no HPI here, nor is there a chief complaint.  This is insufficient to establish any medical necessity to bill an evaluation and management service, unless it is a preventive care visit.  I would query the provider for additional information if this is all you have to go on.


----------



## Rebecca Pate (Jun 12, 2017)

Thanks Thomas!  That's what I was thinking, just wanted a "2nd opinion".


----------



## MikeEnos (Jun 13, 2017)

Rebecca Pate said:


> I need some help with this one.
> 
> "25 year old patient presents for initial visit.  Husband is in the military and was transferred here 5/2017.  *She is here to establish care*.  She saw her GYN 2/2017 and IUD was still in place."
> 
> ...



The phrase "here to establish care" tells you that this is an annual preventive exam, not a "sick visit."  There is no sufficient chief complaint or HPI to support a sick visit.


----------



## CodingKing (Jun 13, 2017)

MikeEnos said:


> The phrase "here to establish care" tells you that this is an annual preventive exam, not a "sick visit."  There is no sufficient chief complaint or HPI to support a sick visit.



It could also be a get acquainted visit which would not be billable at all. No way to tell without the exam information.


----------

