Wiki Reusing Office Visit Note for H&P

[danielawhit]

I have a doctor that will see a patient say on the fifth of the month then admit the patient on say the seventeenth. He then uses the office visit note from the fifth (he is very good at documentation) and marks that there are no changes from the prior H&P and attaches the office note and makes a seperate note to include any updated decision making that has occured. My question is can we bill for both the office visit on the fifth and the H&P on the seventeenth? My thoughts are no but I am having problems finding documentation to back that up and this doctor wants documentation (not that I blame him).

 

[CatchTheWind]

You are asking whether you can count HPI points when the HPI is just brought forward from the previous visit with a comment that there are no changes, right?

I have had essentially the same question: Can you count HPI points if the provider did not actively enter the HPI on the follow-up visit - it was automatically entered by the EMR system by bringing these elements forward from the previous visit for the same problem - and by signing the note, the provider indicates that this HPI is still accurate.

I still have no answer to the question:

Here is the thread: https://www.aapc.com/memberarea/forums/showthread.php?t=120216

 

[jdibble]

You are asking whether you can count HPI points when the HPI is just brought forward from the previous visit with a comment that there are no changes, right?

I have had essentially the same question: Can you count HPI points if the provider did not actively enter the HPI on the follow-up visit - it was automatically entered by the EMR system by bringing these elements forward from the previous visit for the same problem - and by signing the note, the provider indicates that this HPI is still accurate.

I still have no answer to the question:

Here is the thread: https://www.aapc.com/memberarea/forums/showthread.php?t=120216

I have this issue with my physicians also. With the EMR they use, they have a drop down arrow and can choose a past HPI to poputlate into the current note. They do not touch this previous information brought forward and then add at the end of the documentation a short comment for the current situation - i.e. no further complaints, or chest pain improved. I do not count the "old" information because it appears that the doctor has not even reviewed it. I have HPI notes such as - "Patient has chest pain for the past 2 weeks on exertion" and then at the end of the HPI she states "no chest pain". Then when I pull the old HPI I see that they have pulled forward the previous HPI for the last six months for every visit - each one stating the patient had chest pain for 2 weeks! So, no, I do not count any of the old HPI and only use the new information that was added.

 

[teresabug]

I agree with Jodi. Providers cannot "clone" or "copy and paste" data. That is one of the main downfalls of EHR's. Auditors will look at previous E/M's on the same patient to see if the information is "exactly the same". I beleive Codepedia.com has a great article on this topic.

 

[jdibble]

I have a doctor that will see a patient say on the fifth of the month then admit the patient on say the seventeenth. He then uses the office visit note from the fifth (he is very good at documentation) and marks that there are no changes from the prior H&P and attaches the office note and makes a seperate note to include any updated decision making that has occured. My question is can we bill for both the office visit on the fifth and the H&P on the seventeenth? My thoughts are no but I am having problems finding documentation to back that up and this doctor wants documentation (not that I blame him).

This sounds like cloning a medical record which is not acceptable! Did your doctor have a face-to-face visit with the patient to admit him? Is this a planned admission or is he admitting the patient for an illness/injury? If this is a planned admission, then he would not bill for an H&P for the admit. My surgeons would see the patient and update the H&P for the hospital record, but they did not bill for another H&P. If he didn't see the patient face-to-face, he can't bill. And if the patient is being admitted because of an unplanned issue, the doctor needs to do a complete new H&P with current information for that visit. Anyway I see it - he should not bill for the second visit unless his documentation is current.