tci E/M Coding Alert - 2014 Issue 8

Clarify the HPI Guidelines Change with an Example

Break down your options and see which gives you highest code level. With the new Medicare policy, you can mix 1995 with 1997 to get the best HPI and exam for your clinical circumstance in order to determine the highest code level. Take a look at this clinical situation and the possible coding options.   Example: An existing 52-year-old male patient comes to see your physician. Your provider documents a chief complaint, more than 10 systems reviewed in review of systems, and complete past medical, family, and social history. For HPI he writes the following: “Patient’s hypertension...

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