Wiki No HPI for sick visit

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I would appreciate help on the following question. How do I code a history if the CC and ROS are documented, but the HPI is missing for a follow up/sick visit? Thank you.
 
Any statements in the rest of the note that could be an HPI element - even in the CC? I have had that - "cough x 2 days" as CC at least would give me a duration. Or even in the assessment? It doesn't necessarily have to be in a section labeled HPI to recieve credit for it.
 
I'm with Lance... would you mind giving an example of a note that you feel has no HPI? I bet there's at least 1 HPI element.
 
Thank you for your help. I had this chart whose CC said the patient is here for a follow up and the HPI was "28 year old male here for suture removal". In this case there was no ROS either.
 
Wow thank you. I do coding for a medical clinic in which there are several providers. So if the patient came in and one of our providers put the sutures in and came back to have them removed, even if another provider took them out we are not allowed to bill an E&M code?

Can I give you another example? CC - "This 22 year old female presents with WIC." HPI - "Here for a WIC appointment". I'm guessing this doesn't get an E&M either?

Thank you very much for your help.
 
tovygoldstein said:
Wow thank you. I do coding for a medical clinic in which there are several providers. So if the patient came in and one of our providers put the sutures in and came back to have them removed, even if another provider took them out we are not allowed to bill an E&M code?

Can I give you another example? CC - "This 22 year old female presents with WIC." HPI - "Here for a WIC appointment". I'm guessing this doesn't get an E&M either?

Thank you very much for your help.
Click to expand...

For suture removal check with the payer, in 2011 Medicare deemed minor lac repairs now have 0 global days so you can charge an E&M to remove them but you need to know what type of repair was originally billed to know. Your dx code is V58.32(do not code the injury)
For ICD-10 the dx code will be the injury with a 7th character D(do not code the Z code for suture removal) + the external cause code with the 7th character of D

As far as "here for WIC" encounter , could this be a preventive?
 
There has been a change to the simple repair codes (previous link dated 2009). The simple repair codes no longer have a 10 day global period. When they changed the global days from 10 to zero days, they also reduced the RVU's (which is why some providers choose to bill a low visit E/M; to make up for the RVU difference). As a result of the global day change, you can charge a low visit E/M code; however, keep in mind that the insurance company may impose a copay/co-insurance. The "S" HCPCS code (Removal of sutures; by a physician other than the physician who originally closed the wound ) is carrier specific.


Oops...We were typing at the same time, Debra.
 
Re: the "WIC appointment" - without the note, hard to say, BUT...if there is nutritional counseling in this appointment and there is proper documentation (total time spent, 50% or more spent on counseling or coordination of care), this might be able to be assigned an E/M code using time.
 
Thank you everyone. So it looks like I am back at my original question - how would I code the HPI for the suture removal?

Regarding the WIC encounter, the provider did a finger stick for hemoglobin. The ROS just states the patient is perimenopausal. The Past history does state the patient is not currently pregnant. Can I use that as a context element for an HPI? It is obviously not a preventive exam, though.
 
Just came across another one: CC- "This 52 year old male presents with f/u labs." HPI - "came to discuss bloodwork". This patient was seen in the clininc for a well visit about two weeks prior. He had bloods drawn and is coming back now to discuss the results with the provider. Can this visit get its own E&M code?
 
99211

99211 requires nothing more than a chief complaint.

YES, an MD can use this E/M code, it is NOT restricted to "nurse only" ...

However ... If the patient is ESTABLISHED - your exam and MDM may be sufficient to bill a higher level of established patient visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
tovygoldstein said:
Just came across another one: CC- "This 52 year old male presents with f/u labs." HPI - "came to discuss bloodwork". This patient was seen in the clininc for a well visit about two weeks prior. He had bloods drawn and is coming back now to discuss the results with the provider. Can this visit get its own E&M code?
Click to expand...

Sounds like another visit where time could be used if documented properly - total time, 50% or more for counseling, etc. Again, would need to see the documentation, but yes, it is possible.
 
What do you think of counseling codes:

V65.49 - Other specified counseling, includes Health: advice, education, instruction

and

99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an indivudual (separate procedure).

I'm just afraid this visit would be a continuation of the well visit and included in the well visit code?

Thank you all for your help.
 
After posting my reply I noticed the 99401 excludes "Counseling services provided to patient groups with existing symptoms or illness (99078)." I can't seem to find a code equivalent to 99078 for an individual patient and the patient in the scenario does have known conditions. Does such a code exist?
 
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