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Marlene Posted Tue 23rd of February, 2016 23:32:42 PM

Would this HPI count as a 99203? 4 or more HPI?

This is a 93 year old male who comes in for a chief complaint of a new lesion of the right superior helix. The new lesion is red and mild in severity. The new lesion has been present for 3 months.

The doctor is also billing the excision of the lesion in addition to the 99203 with mod 25. He documents ROS - Past History. so meets the other requirements. I have a hard time with knowing when it is ok to add an e/m with procedures. Any reference would be helpful.


SuperCoder Answered Wed 24th of February, 2016 08:09:10 AM

Thanks for the Query

HPI counts 4 points as per the documentation provided here for HPI.

Please go through the undermentioned link for your queries on E&M and procedures performed together.

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