Wiki Satisfying cc/hpi

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REGINALD068

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Good morning fellow Coders

I am reposting this question because I only received one opinion. I'm sure I can't be the only one who's somewhat perplexed about this question, so here it is again....

When billing any level of E/M service, say for example, does the patient have to have 4 different chief complaints with HPI, or is it a combination of both to bill a 99214?

Example: Pt presents with CC of low back pain which radiates to lower extremities with numbness and tingling.

Given the above example, the patient is only complaining of back pain with HPI of radiating pain, numbness and tingling. Would this be considered 1 CC?
 
Giventhe example of “Pt presentswith CC of low back pain which radiates to lower extremities with numbness andtingling.” This would be leveled at:

Location = Low Back
Quality = Radiates
S&S = Numbness and Tingling

Sowith the documentation above without looking at the ROS or PFSH, would put thisin line for a PF or EPF level for history. In addition, the chief complaint would be defined as "low back pain."

ProblemFocus = 1-3 HPI
ExpProblem Focus = 1-3 HPI with 1ROS
Detailed= 4 HPI with2-9 ROS, PFSH 1
Comprehensive = 4HPI with 10+ROS, PFSH 2-3
 
Thank you for the response, but that is my dilemma. For a 99214, it requires 4 or more CC with HPI. I previously posted this question on here and was told it is a combination of CC/HPI and not necessarily 4 separate CC with HPI. The entire office is confused about this. Is it a combination, or does the patient have to have four separate complaints to bill 99214? No one can seem to give a clear answer
 
Between the CC and the HPI for a level 99214, yes, you would need 4 elements. So if in your example you listed:

Chief Complaint = Low Back Pain

HPI = The patient is being seen today for low back pain that is radiating causing numbness. This has been ongoing for 2 weeks.

You now have enough elements to consider a 99214;

Location = Low Back
Quality = Radiating
S&S = Numbness
Duration = 2 weeks

4 elements identified between the chief complaint and the patient history.
 
You don't need four separate CC, just four of the elements related to HPI (location, quality, severity, duration, timing, context, modifying factors, or associated signs and symptoms). You can get an HPI of 4+ from one CC if the problem is described in enough detail.

The specific number of problems and complaints or diagnoses would play more of a role if you were billing based off of MDM.
 
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