Wiki How to Code w/No HPI

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tlewiscpc

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I have a provider who documented a new patient visit with the following:

no HPI
complete ROS
complete PFSH
comprehensive Exam

Did additional workup ordering a gene test

This patient was seen d/t a strong family history of hereditary breast cancers to discuss risks and to see if he (yes male - not a typo) should have the BRCA gene test

Provider should have documented and billed based on time but he didn't so I'm not sure how to code.

What do you do when there's no HPI for a new patient?

Also, what would you consider the risk to be? Patient isn't having any symptoms or issues related to this but only the strong family history.

Thanks.
 
I belive it should be preventive service., because there is no CC and more overin the last sentance you said the Patient isn't having any symptoms or issues related to this but only the strong family history. some times CC can be obtained from HPI, but here HPI aslo is not there, that means patient is not coming for a certain problem. so it should be 9938X series. Lets wait for others opinions.
 
I agree, this sounds like an encounter that is preventive in nature, and should be billed as such. I would suggest taking a look at 99401-99412 to report Genetic counseling and/or risk factor reduction intervention from a physician or other qualified health care provider provided to patients without symptoms/diagnosis. Many of these codes are time based, so the note will need to have an addendum added with the length of the counseling.
 
Thanks all. I really appreciate the help. We sometimes have patients coming in simply to talk to the physician about family history and what they should do or consider in light of such. This will be helpful going forward.
 
Follow up question. Medicare doesn't cover those codes from what I can tell.

If the patient was Medicare, then what would the coding end up being? We are a specialist so we don't do the Welcome to Medicare exams or annual exams.
 
No HPI

I would appreciate help on a similar question. How do I code a history if the CC and ROS are documented, but the HPI is missing for a follow up/sick visit? Thank you.
 
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