Primary Care Coding Alert

Question: I was at a seminar recently and heard a speaker say that details gathered at the time the patient checks in for his or her appointment can count toward the history of present illness (HPI). Is this correct?

Minnesota Subscriber

Answer: Yes, as long as the information is transferred to the physician from the office staff and fully documented in the medical record. Your practice can begin gathering information for the HPI the minute the patient walks into your office. For instance, the receptionist may ask a patient why he scheduled the appointment. The patient tells her that he has had a cough and low-grade fever for three days. The receptionist may enter this information into the computer scheduling software, which can be shared with the physician, as well as the coding and billing staff. These details, confirmed with the patient, may be included when subsequently determining which level of E/M service is to be billed for the appointment.