Wiki E/M with no seperate HPI

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kburow5446@gmail.com

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I have a provider who is refusing to add a separate HPI for his ER visit for several patients. I just started coding for this provider as someone else has been in the past. Apparently this is common with him and he has never responded to the previous coder when asked to add his HPI. So he has his CC as well as ROS, PFSH, Exam and MDM/plan all listed (these are all documented very well).
However under the HPI it simply states that an interpreter was not used. I have sent him queries to add his HPI. He responds and will not add one. I questioned the coder who has been coding for him for years and she said he is not very responsive and is getting ready to move and is not very motivated to change his ways. Her response to me was "I just try to pull something out and code it".
Can I pull out symptoms from the ROS and count that for 1 element of the HPI so I can at least get a low level? I have never had to do this before and I am not sure that can be done. I know you can pull ROS out of the HPI. Other then that I don't know what else she could be pulling out to count towards the HPI. I really don't like it.....but....considering he is only here a few more weeks...it doesn't pay to make a huge fuss right now. Can I bill a 99281 otherwise with out a clear HPI?

I guess I am wondering if the HPI is not listed separately can we really bill an E/M?

Thank you
Kelly, COC
 
If you've got a location...

If you have the location (or any of the HPI elements is referenced??) and there is at least one additional organ system referenced in the ROS, you might be able to eke out a 1.

Ugh.
 
A little more information is that no there is no other information such as location. One example is the CC states "low blood sugar" or another "cough". That is it. Some are saying the "low" could be the severity or quality...I guess maybe...but what about "cough"?
 
Remember that you cannot count elements twice. So what you use for HPI cannot be used for ROS. I always look at HPI as those things related by the patient as to why they are here, and ROS is that which they state yes or no responses to do you have or have you had. So given what the chief complaint is, then what in the ROS relates from the patient perspective to that.
 
I do know you can not double dip and use something as an ROS and HPI. This provider listed a very good ROS, exam and plan.

He lists a chief complaint such as "cough", "low blood sugar" or "chest pain and headache". Then there is no HPI at all. But a complete ROS. In the ROS it might list a more specific location of the chest pain....it might not.


I have been getting lots of thoughts. I just have never had to code from notes like this before. Thankfully!
 
Yeah, it's tough when providers are not being very responsive. When applicable and appropriate, I have been able to use something from the CC as perhaps one element for the HPI, but usually that is not the case. Unfortunately, without an HPI there can be no History. Without an History you cannot bill an ER E/M visits.
 
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