# exam documented under hpi



## williafm (Apr 16, 2009)

I have a specialist that under the HPI note section of the patients record on our EMR "CT scan shows no inflammatory process or mass, also no hernia.  The Left-sided tenderness is significantly decreased.  Exam is unremarkable.  No evidence of abdominal surgical disease at this point.  RTC prn." There is nothing under the exam part or ROS. I told him it was not billable and that he needed to enter it correctly. He is livid and now my boss wants something in writing stating that the HPI and exam are not interchangable. I know they are not but I can't find it in writing. Anyone know where I can get this?
We use an EMR and his statement is under the HPI heading not under an exam.When the record is generated the statement prints under CC/HPI notes.


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## dmaec (Apr 16, 2009)

well, I may not be understanding your question correctly but:  I don't see an issue... I have several providers who basically dictate in "one paragraph". It's my job to score the visit out, counting the components of each element accordingly....

so, I don't see a problem with your provider dictating everything in one area. Not all providers follow a SOAP format, or other format, but the service is still billable, and still able to be coded if the contents support the elements and services provided...

not sure what you mean by interchangable - of course we can't "double dip" and count the same thing in several area's. but as far as being 'interchangable", just because the exam  & POS components are dicatated in a paragraph under the HPI, doesn't mean they aren't the exam/ros components.

just my opinion.


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## RebeccaWoodward* (Apr 16, 2009)

I agree with Donna,

I, too, have physicians that do not follow the SOAP format.  I actually have one provider that lists the diagnosis as the first line of entry.  I find that each physician is unique in their method of dictation but the method of "scoring" their level of evaluation and management remains the same.


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## FTessaBartels (Apr 16, 2009)

*It's billable*

The note is billable as it stands even if the information is under the "wrong heading."  As long as it is clearly an exam element you can assign the appropriate level of service.

History is clearly not the same thing as an exam. Sounds like this physician doesn't like your EMR format. 

Like Donna and Rebecca, I know physicians who just dictate a paragraph ... it's all lumped together, and it's up to the coder to figure out what's history, what's exam, what's MDM. 

F Tessa Bartels, CPC, CEMC


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