Wiki HPI Help

[brandyb82104@gmail.com]

History Of Present Illness
The patient is a 24 year old Caucasian/White female who has a history of scoliosis, cervical spine disease, ADHD, arthritis, migraines. She presents today for a new patient visit and to establish care and has no current symptoms.
The patient denies chest pain, dyspnea, and fever.
Medications are listed in the medication list.
The patient has no medical records available for review.
The patient has had the following health maintenance exams: Pap smear and Breast exam Pap: 2015-normal Breast Exam: 2015-normal
The patient has had the following preventative vaccines: Tetanus and Influenza Tetanus: 2015 Influenza: 2016
The patient comes to this office visit alone today. The patient is able to do own activities of daily living. The patient is able to ambulate without assist.

Am I wrong that there is no "HPI" in here? How do I bill for a new patient visit if it requires all three components and there is no HPI?
Can I bill an established code instead so it is not a complete loss?

 

[thomas7331]

I agree with you that there is no HPI, nor is there a chief complaint, so there is no medical necessity documented to justify billing for anything.

This is actually something that I've seen very frequently with primary care providers and it can usually be corrected with some basic education. 'Establishing care', in my opinion, does not by itself give sufficient medical necessity to warrant billing an E&M service - if this is truly the nature of the visit, a 'meet and greet' so to speak, then it should be provided as a courtesy to the patient. In fact, though, most patients come to establish care because they need a new provider take over management of their chronic illnesses. All the provider really needs to do it state this and that would qualify as a chief complaint and HPI. If there are three or more chronic illnesses and the provider documents a brief status of each of them, that would satisfy the HPI requirement for any level of new patient visit.

 

[brandyb82104@gmail.com]

So there was an actual C/C
Chief Complaint
Est. Care
ADHD
scoliosis
Cervical spinal disease
arthritis
migraines

and physician ordered blood work and gave prescription. So there is medical necessity, but just no HPI. I guess I will query the doctor and see if she can finish the HPI.

Thanks for the input!