Wiki How code I code if HPI is missing?

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benaxixon

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HI,
I don't know if this is correct. Please help.
I have nothing for HPI, a "complete" ROS, and "complete" Past, family, and social history.
Would the level for History be "problem focused"? There is no HPI. Thank you.

exam: case 8
New patient, last CPE and labs w/MD in LA in August, report wnl needs mammo order as last one 2-3 yrs ago. h/o L benign breast lesion removed never had colonoscopy.
 
This would be a well care, 9938X-9939X, which does not require any specific elements it is based on patient age.

Laura, CPC, CPMA, CEMC
 
benaxixon said:
My physician coded as a new patient visit 99203
I have the exam: EPF and MDM: low. Can I use 99201?
Click to expand...

All new patient E/M codes 99201 to 99205 needs a chief complaint & HPI, even 99201.

99201 needs the Chief complaint & 1-3 HPI elements so I would think You can't code it.
 
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