Wiki E/M level

[Triesen1]

I have two questions.
1. If the physician does NOT document the HPI on an established patient, can we bill an E/M level? My thoughts are that you only need 2 of 3 elements to be met to bill but I am not sure.

2. For a new patient, if you list the 3 chronic conditions in the HPI and include there status is that significant enough to get a comprehensive HIP without meeting the 4 or more HPI elements. I know with an established we will meet the exam and MDM as detailed and moderate so we don't generally have to worry about that but with a new patient I was not sure. Thanks!

 

[thomas7331]

For question 1, you're correct - for an established patient you only need 2 or 3 elements, so an HPI is not required if you have the necessary exam and MDM. (A chief complaint is still required though.)

For question 2, the status of 3 chronic conditions does qualify as an 'extended' HPI but the other history elements of a complete ROS and complete PFSH are still needed to get you to a comprehensive history. HPI alone does not meet the history requirements.