Wiki "Please see the patients previous evaluation for more details of the history."

[jdd111168]

"Please see the patients previous evaluation for more details of the history."

My doctor often uses this phrase for f/u pt's. Is it acceptable to refer to the previous exam for HPI when coding the office visit?
Thanks in Advance for any help!

 

[roxvaughn]

Nope not for HPI! he could just say, " pt here for follow up on so and so condition, no changes since last exam..."

 

[emcee101]

you would not get credit for any of the information in the last encounter. This section is called History of Present Illness because it is used to describe the status of the symptoms or clinical problems from time of onset or since the previous encounter with the physician. This must be current and unique to each encouter with the patient.

 

[BenCrocker]

To me it looks like the Dr is doing the 2 out of 3 things required to pick an E/M code. I don't think it's up to them to eliminate one of the things we need to do our jobs accurately. Plus it's just lazy.