Wiki Subsequent Hospital Care - Subdural Hemorrhage

[mbabou]

I have a quandry I am hoping to get a consensus on. I have a provider that is performing subsequent hospital care. This provider is copying the HPI from their initial inpatient consultation, ex. " Patient presented to ER 8/1/09 for severe headache and blurry vision. A CT was performed in the ER and indicated a Subdural Hemorrhage. She was admitted by the hospitalist service and a Neurosurgery Consultation was requested. Neurology is also following the patient for a history of seizures." This provider is then adding a subjective heading for the interval history(sometimes several days after the HPI was done). The issue is her subjective sometimes states " no complaints." My problem, I don't feel I can use the copied HPI as a reason for the visit several days after the admission has occured without an interval history stating as to why the patient needs to be seen each day or at least containing a CC. Another coder I work with believes this is billable. Can anyone offer their opinion on whether or not they would accept this HPI or not?

 

[FTessaBartels]

2 out of 3 key elements

For a subsequent hospital visit you need only 2 out of 3 key elements: History & Exam / History & MDM / Exam & MDM

I would give credit for the CC from the copied HPI ... subdural hemorrhage, headaches, blurry vision

"No complaints" is totally inadequate for an interval history, however. "No headaches, vision clear" would be a different story, as it would tell me WHY the patient is being evaluated.

It is still possible that the exam and MDM are enough for the level of service. So I can't say from the limited info provided whether this note is billable or not.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[LLovett]

I agree with Tessa, I would give credit for a chief complaint but nothing else unless they are adding to it, which it doesn't sound like they are.

We have providers that do this but they are actually goining in and editing the info and updating it, they don't usually copy it everyday though.

On a side note, most of my subsequent care days are leveled based on exam and MDM anyway history is sorely lacking on the inpatient side (at least for the facility I currently work at).

Laura, CPC, CEMC