Tag Archives: history
Posted on 30. Apr, 2010 by Editor.
A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.
How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report these incidents.
When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.
Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you’ll need to code correctly each time.
Posted on 26. Feb, 2010 by Editor.
Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?
New Jersey Subscriber
Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any NPP.
If the provider spends at least half (16 min) of the total session time counseling the patient, then report …