Wiki No C/C or HPI

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Bethy4444

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We have a provider who regularly does visits to NH, domiciliary, rest homes, etc... where the PTs don't always have a chief complaint. They are either being seen because it's required, or as a routine exam. There really is no HPI either, as they have no C/C, and nothing has changed with them over time. My provider likes to call it an interim history, but then states, "PT has had a quiet interim" and then goes straight into the PFSH. How are you to document such cases, so I can correct her and tell her? I'm not even sure myself. Thanks in advance for any responses!;)
 
Bethy4444 said:
We have a provider who regularly does visits to NH, domiciliary, rest homes, etc... where the PTs don't always have a chief complaint. They are either being seen because it's required, or as a routine exam. There really is no HPI either, as they have no C/C, and nothing has changed with them over time. My provider likes to call it an interim history, but then states, "PT has had a quiet interim" and then goes straight into the PFSH. How are you to document such cases, so I can correct her and tell her? I'm not even sure myself. Thanks in advance for any responses!;)
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Well, every visit must have a CC. Also, in absence of HPI she can document 3 chronic conditions instead. If there is documentation outlining the status of 3 chronics then you have your HPI. Then move on to either MDM or PE. I am assuming this in an EP, so you only need 2 of 3. Whichever makes the most sense in this case. Look at the documentation, if there are tests ordered, records or labs reviewed then you can get your 2/3 with HPI and MDM. If the provider touches the patient, then you might can get HPI and PE.

It really depends on what the provider documented. But I can probably see at least a 99212 or 99213. Otherwise, it's a "I said hi, she said hi" and it's a 99211.

Just my opinion.
 
"Every visit must have a C/C"... is my problem. What if there are no complaints? Like I mentioned, these PTs are not requesting to be seen, they just are. I know you can't just put "follow up" for a C/C, so I'm stumped as to what she should put down. Thank you for your response, btw...:)
 
The chief complaint can be ... patient here for follow up, or patient being seen for mandatory exam, the cc is the reason why they are being seen in the patient's own words ....
 
I've also come across the no HPI thing from my hospitialists on the subsequent visits. I make sure they do have a c.c. but what if they only have exam & MDM. I can just use those for my 2 out of 3, right?
 
We had some professional lady come visit our chapter once, and I can't think of her name, but she was super smart and a super good coder, but she addressed that issue. I'm not sure how to explain it well, but two out of the three must meet the requirement, does not mean that all 3 must be documented. It only means that out of the three you document, 2 of them must meet this certain level for billing. You still have to document all three. Case in point, would you ever pay a physician who took a history, met the required MDM, but didn't do an exam?? Sounds crazy, huh? :)

HTH!;)
 
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