Wiki Initial Hospital Care without a Detailed hx and exam

CatchTheWind

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The lowest level code for initial inpatient visit requires a detailed history and detailed exam. So how do you code the visit if the history and exam were only problem-focused or expanded problem focused?
 
Even though this is an initial visit, it is acceptable to code this as a subsequent visit if only a PF or EPF history and/or exam is documented.
 
Even though this is an initial visit, it is acceptable to code this as a subsequent visit if only a PF or EPF history and/or exam is documented.

It is only acceptable if the physician is not the admitting physician. If it is the admitting physician then he would need to be queried about the PE and HPI.
 
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