General Surgery Coding Alert

Question: A new patient visited our office for evaluation for an umbilical hernia repair. Although the surgeon documented "umbilical hernia" in the medical assessment as the chief complaint, he didn't document ROS or a full HPI. The physician completed an extended, problem-focused exam and medical decision making of low complexity. What should we bill for this encounter?

California Subscriber

Answer: Because the surgeon doesn't document history of present illness (HPI) for this new-patient encounter, you don't have a billable service.

According to guidelines, the physician must document the HPI and the exam (with the exception of 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. If you truly have no HPI documentation, you cannot submit a claim 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 is 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.