Wiki E/M Coding

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shofner14

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Can an exam component be mentioned in the HPI? If so, can it be counted toward the required exam components listed under the 1997 guidelines?
 
I'm not sure if that would fly, since they are two different types of information, the HPI gathered from the patient and the exam info based on the provider's exam. Perhaps I'm misunderstanding the question. Do you have an example?
 
An example would be "neurovascular status is intact" within the HPI and then a description of what the patient told the doctor about location of pain or injury, duration, modifying factors etc. Then the physician will state "there are no effusions" which is also listed in theHPI.
 
There is no guideline that states that any portion of the note has to be listed under a specific heading in order to be counted (it would make our life easier though). Therefore, an HPI element or ROS element could be listed anywhere in the note - or the doctor could do a note that appears to be all one paragraph and contain all of the elements to bill an E/M. We had one provider that had 3 page run-on paragraph without any headings intersperesed with numerous "at this time" statements that contained everything for the E/M and then some...such as what the patient's visitor was having for lunch! It was not an easy job pulling out the information needed, but it was usually there and usable!

So, if it is obvious that this was the doctor's observation and not the patient's, then I would use it towards the exam! :)
 
I understand now. I don't see where that would be a problem as long as the documentation is clear that the finding is based on the doctor's exam.
 
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