I have a provider who is refusing to add a separate HPI for his ER visit for several patients. I just started coding for this provider as someone else has been in the past. Apparently this is common with him and he has never responded to the previous coder when asked to add his HPI. So he has his CC as well as ROS, PFSH, Exam and MDM/plan all listed (these are all documented very well).
However under the HPI it simply states that an interpreter was not used. I have sent him queries to add his HPI. He responds and will not add one. I questioned the coder who has been coding for him for years and she said he is not very responsive and is getting ready to move and is not very motivated to change his ways. Her response to me was "I just try to pull something out and code it".
Can I pull out symptoms from the ROS and count that for 1 element of the HPI so I can at least get a low level? I have never had to do this before and I am not sure that can be done. I know you can pull ROS out of the HPI. Other then that I don’t know what else she could be pulling out to count towards the HPI. I really don’t like it…..but….considering he is only here a few more weeks…it doesn’t pay to make a huge fuss right now. Can I bill a 99281 otherwise with out a clear HPI?

I guess I am wondering if the HPI is not listed separately can we really bill an E/M?

Thank you
Kelly, COC