Coding and Documentation
Answers to Your Questions
Fam Pract Manag. 2000 Oct;7(9):23.
Newborn admission, H&P on date of discharge
I performed the admission, history and physical for a newborn on the same date that the baby was discharged from the hospital. Is there a CPT code for this?
Yes. It's 99435, “History and examination of the normal newborn infant, including the preparation of medical records (this code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date).”
HPI or ROS?
A large percentage of my patient visits are for follow-up of chronic conditions which, when well-controlled, are asymptomatic. This makes it difficult to determine what elements of my history constitute History of Present Illness (HPI) vs. Review of Systems (ROS). For example, when I ask a patient with stable angina if he has chest pain and he answers no, does our exchange count toward the HPI or ROS? What about when I ask the same question of a patient with hypertension or diabetes? For a patient with diabetes, should questions about polyuria and thirst count toward the HPI while questions about visual changes or skin problems count toward the ROS?
Here's why the distinction matters: The history taking for chronic conditions does not involve the usual HPI elements outlined in Medicare's documentation guidelines. One can do a great deal of important and relevant history taking and, if that history gets assigned to the ROS, not reach a high enough level in the HPI to use the higher, and probably more appropriate, evaluation and management (E/M) codes. If, on the other hand, it is reasonable to include these items in the HPI, then 99214 is more easily within reach.
As defined in the 1997 version of the documentation guidelines, the HPI is “a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.” The HPI includes such things as location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. In the case of a chronic or inactive condition, the HPI often describes the status (e.g., controlled) of the condition.
According to the documentation guidelines, the ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.” The documentation guidelines note that the ROS may be listed as a separate element of history or may be included in the description of the HPI. Consequently, as your question suggested, the distinction between HPI and ROS can be fuzzy.
In general, the questions you ask regarding chest pain, thirst, etc., probably relate to the ROS, since they represent “a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.” The results of the ROS may facilitate your HPI. For example, you may be better able to identify “associated signs and symptoms” from the ROS.
As you noted, the elements of HPI (e.g., location, quality, severity, etc.) do not follow the chronic illness model, such that it can be difficult to document an extended HPI for a patient with less than three chronic conditions (the HPI automatically qualifies as extended when the patient has three or more chronic conditions). However, it's not hard to imagine the HPI for a patient with diabetes and hypertension covering quality, severity and duration plus associated signs and symptoms. That's enough for an extended HPI, which supports a detailed history and — with either a detailed exam or decision making of moderate complexity — 99214.
How should CPT code 17003 be used?
Code 17003 is for “Destruction by any method, including laser, with or without surgical curettement, all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions, including local anesthesia; second through 14 lesions, each.” This code should be submitted in addition to the code for the first lesion, 17000, and it should be listed repeatedly for as many lesions as were destroyed. For example, if you destroyed three lesions of the type described by the code, you would submit code 17000 for the first lesion, and 17003 twice — once for the second lesion and once for the third. If you destroy 15 or more such lesions, you should submit code 17004 once, regardless of the number of lesions you destroy. Do not use code 17000 in conjunction with code 17004.
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