Gastroenterology Coding Alert

Question: A new patient visits the physician with a chief complaint. I don’t have a review of system (ROS) or full history because the doctor didn’t document a history of present illness (HPI). He did include a brief HPI in the medical assessment that I credited toward the chief complaint. The physician completed an extended, problem-focused exam and medical decision making of low complexity. Can we bill for this encounter?

Minnesota Subscriber

Answer: According to guidelines, the physician must document the HPI and the exam (with the exception being vitals, which a nurse or PA can document). You need documentation of all three key components (history, exam, and medical decision making) to support a new patient level E/M code.

The documentation guidelines for E/M services also state that the chief complaint, ROS and past/family/social history, may be listed as separate elements of history, or they may be included in the description of the history of the present illness. In your case, rather than crediting the brief HPI toward the chief complaint, consider counting the chief complaint as part of the brief HPI. With a chief complaint and brief HPI, the physician has documented a problem-focused history to go along with the extended, problem-focused exam and medical decision making of low complexity. Together, they would support billing 99201 (Office or other outpatient visit for the evaluation and management of a new patient . . .) for the encounter.

Established difference: If you were coding this scenario for an established patient, you could report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …).

Follow up: Help educate your physicians on the importance of clear E/M documentation. The HPI along with a Review of Systems and some Past Medical Social History are a vital part of the patient record that documents the nature of the patient’s problem and what has happened since the patient’s last visit.

If a physician routinely omits the HPI, you’ll be hard pressed to establish medical necessity for many patient encounters and you may be prohibited from reporting the encounter at all without an HPI if the patient is new.