Wiki HPI on a follow-up problem

[CatchTheWind]

If a patient comes in for a follow-up visit and the provider (or the EHR) pulls the "non-changing" HPI elements (ie: location, duration) from the previous notes, can you get HPI points for these?

 

[teresabug]

a provider should not be cloning documentation in any part of the note. If nothing has changed, then what is the reason that the patient had to be seen?

 

[AmandaBriggs]

I agree with Teresa. As an auditor, if I find any portion of the HPI, physical exam, or assessment & plan has been cloned I cannot give any credit for the cloned content. This is on the radar for both Medicare and the OIG.

 

[CatchTheWind]

I didn't mean that nothing has changed. Here's an example of what I mean: The patient has an itchy rash, for which the provider wrote a prescription and instructed the patient to return in two weeks. When the patient returns, the provider chooses the chief complaint in the EMR, and then answers the EMR's "question" as to whether this is initial encounter for this problem or a follow-up encounter. If it is a follow-up encounter, the EMR pulls certain information (such as the location and duration of the problem) from the original encounter and populates these into this encounter.

I do not believe that it is a problem to do this (correct me if I'm wrong!), but I don't know if we can count these elements (ie: location and duration in the example above) toward the HPI points.

 

[ladeeh]

this is a great question.... referencing the example- count any new HPI elements that developed from the previous encounter to the present. For example, is the rash in a new location (location) or after taking rx for 2 wks - has it gotten worse or better (modifying factor)? and so forth.....