Wiki Hpi

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KaylaRieken

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Provider is seeing a new patient. The patient has multiple problems. In the HPI does the provider need to have 4 elements for each problem? I am running into issues where the patient is being seen for Problem A and they are listing 4 for HPI but only doing a lab for that issue. For Problem B they are only listing 2 HPI and are prescribing a medication. They hit everything else in the document to code a 99204, but I am questioning if I can do that since they only have 2 in HPI for the Problem B. Am I making any sense? lol
 
To be able to bill a 99204 the provider must meet 3 out of 3 for the History, Exam, and MDM. For the history portion the provider must document:

- HPI 4 criteria
- ROS 10 criteria
- PFSH 3 criteria

Problem A and they are listing 4 for HPI but only doing a lab for that issue.

For the history section, if you had the 10 ROS and the 3 PFSH then for the history you would level a 99204.
The exam and MDM must also level a 99204 for that code. It sounds liked the MDM is the issue.

For Problem B they are only listing 2 HPI and are prescribing a medication. They hit everything else in the document to code a 99204, but I am questioning if I can do that since they only have 2 in HPI for the Problem B.

If they only have 2 HPI then they would not level a 99204. This would level at a 99201 or 99202 depending on ROS and PFSH.


Please let me know if this did not address your question. :)
 
Thanks for replying. So I guess I am trying to ask is if I have multiple problems that my physician is seeing the patient for, he needs to document 4 HPI elements for each problem? Does that make sense?
 
No, he does not need to list 3 HPI elements for each problem discussed during the history of the visit. The total for all problems discussed needs to be four.

Example: Patient is being seen today for low back pain which is 8/10 on the pain scale. In addition the patient has had a fever for the past 2 days. He has taken Tylenol which has helped to reduce the fever. Continues to take medication for HTN.


Location = Low Back
Severity = 8/10
S&S = Fever
Modify = Tylenol reduces fever

So even though multiple issues were discussed in history, it is the total of the elements for all of the issues and not the elements per issue.
 
Ok Thanks. I was confused on that. It happens where our doctor will dictate 4 HPI elements on stones, and then only 2 for ED, and in the MDM he orders CT for the stones and then will prescribe a medication for the ED. I wasn't 100% sure on how that worked.
 
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