Forum - Questions & Answers

Mar 21st, 2012 - kccaubuchon

E/m hpi

I am trying to brush up on my E/M coding and I have a question regarding chosing the level of history with F/U patients.
For example:

Pt came in with F/U on biopsy
all lab results listed
ROS is 2
PFSH is 3

No true HPI??? do you code the History as detalied??? (2 out of 3) Or do you pull the history form the ROS?

Please help I am a bit confused on this.
Thanks

Mar 21st, 2012 - Codapedia Editor 1,399 

re: E/M HPI

Can you tell us what exactly the history said? I'm not sure without seeing it in writing.

I assume this isn't in the global period for the biopsy.

For history, you do need all three components, so for a detailed history, you would need four HPI elements. Download an audit sheet from your Medicare contractors' website.



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