Wiki Hpi?

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btadlock1

btadlock1

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Can anyone find any HPI in this?

"Snoring per family report. Patient previously underwent a sleep study in 2007 that proved he needed a CPAP @7"

I don't need ROS or PFSH - those are covered elsewhere...just trying to squeeze some HPI outta this...Any thoughts?
 
What's the complaint?

Well, it helps to know what the complaint is ... but I'm going to guess it has to do with sleep apnea.

You possibly have context in that some abnormality was discovered in the sleep study.
You have duration because of the date of the sleep study
You have an associated sign/symptom in snoring.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
You're awesome! Thanks!

BTW - it is for an evaluation to see if the patient is a candidate for a sleep study. That was seriously all that was under the subjective portion. The notes are very limited that I'm working with, so I'll just have to go with what I've got.

New question for you, though - NP renders the E/M, and signs her name and her supervising MD's name (not sure why) - The MD countersigns above his name. I'd still bill under the NP, right?
 
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