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General Surgery Coding Alert

Reader Question:
Skip HPI and Skip Your EM Pay

Question: A new patient visited our office for evaluation for an umbilical hernia repair. Although the surgeon documented "umbilical hernia" in the medical assessment as the chief complaint, he didn't document ROS or a full HPI. The physician completed an extended, problem-focused exam and medical decision making of low complexity. What should we bill for this encounter? California SubscriberAnswer: Because the surgeon doesn't document history of present illness (HPI) for this new-patient encounter, you don't have a billable service. According to guidelines, the physician must document the HPI and the exam (with the exception of vitals, which a nurse or PA can document). You need documentation of all three key components (history, exam, and medical decision making) to support a new-patient level E/M code. If you truly have no HPI documentation, you cannot submit a claim for the encounter. Established difference: If you were coding this scenario for an established [...]