# HPI documentation/Audit



## tracylc10 (Apr 18, 2016)

Hi all, I need some help understanding the history component when auditing an annual exam.  In my study guide it states "The chief complaint is required for all levels of history and is the reason why the patient is presenting for care. In some cases the patient may not have a complaint.  In those cases, the provider should document what the patient presents for.  Examples include annual exam, well child checkup, or follow up for diabetes management.  *If documentation shows that the provider is unable to obtain a history from the patient or other source, the overall level of medical necessity and the work of the provider are not penalized by the fact that the physician could not obtain a history from the patient"*.

This being said, I have a patient that came in for an annual exam and I am wondering how to figure out what the level of HPI would be.  See HPI in chart below:

History of Present Illness:
1. Annual Exam
Currently pregnant: no.  The patient states she uses Depo-Provera for birth control.  Her menses is absent.  Negative for: breast discharge, breast lump(s) and breast pain.  The patient does not use tobacco.  She does not drink alcohol.  Additional information: takes depo for cycle control; patient has CP.


There is an Extended ROS and a Complete PFSH.   How would you decide if this is a brief or extended HPI?


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## StephR (Apr 18, 2016)

Good Morning,

Under the Preventive Medicine Services, there is a section which states the "comprehensive" nature of the Preventive Med codes reflects an age and gender appropriate history and physical exam and is NOT synonymous with the "comprehensive" examination required in E&M codes 99201-99350.  

Steph


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## mitchellde (Apr 18, 2016)

You need to look at the preventive codes for the annual and not the regular office visit codes.  You will see in you CPT book the criteria that must be documented for the preventive, but the preventive does not have the three key component of history, exam, and decision making.


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## tracylc10 (Apr 18, 2016)

Thank you Steph.  I understand that when using the preventive medicine service codes, but my physicians are using 99212-99214 codes for Medicare off year annual exams.  I do not feel that this is correct, but I am also fairly new to the practice and not sure that I can change the way that they have been doing this.  I am guessing that the statement out of my study guide is referring to the preventive medicine codes and not the office visit codes...

I think that I am going to have to talk to my office manager about this.


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## mitchellde (Apr 18, 2016)

No you cannot do this!  By using regular office levels you are able to obtain Medicare reimbursement for an otherwise non covered service.  You must use the correct prevent codes, and obtain a waiver from the patient for the non covered service and attach the waiver on file modifier for the bill to go to patient responsibility.


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## tracylc10 (Apr 18, 2016)

So, I am seeing that they used G0101 and Q0091 last year.  So this year they should use G0439? or a regular preventive exam code?  I also found 
S0612, Gyn exam established pt.  I am so confused on how to code the Medicare annual exams.

A pap was not done on the patient in question.  They did order a screening mammo. 

What I gather from all of this info, is that this visit should have been coded 99396 and the patient should have signed an ABN.  Am I correct?


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## valleycoder (Apr 18, 2016)

You shouldn't need to get an ABN signed as the 993XX codes are statutorily excluded and will be adjudicated to patient responsibility.  With that said, let me forewarn you that the patient complaints will increase dramatically because they are not used to getting a bill since the providers were incorrectly billing Medicare with a sick visit code 99213/4/5 instead of the preventative codes.  A lot of education to the patients will need to take place letting them know that going further these visits will no longer be covered (and shouldn't have been covered in the past).  It's very difficult to change this culture but its not correct coding and billing.  Refunds should actually be made to Medicare.  Sorry for the bad news on a Monday.


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## tracylc10 (Apr 19, 2016)

Thank you for all of this info.


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