Cardiology Coding Alert

Question: If the documentation shows a negative finding for HPI, can I count that?

North Carolina Subscriber

Answer: Yes. Palmetto, the Part B MAC for North Carolina, states that “If a physician documents negative findings for the history of present illness, for example (subsequent hospital visit for chronic heart failure), provider states, ‘Denies any SOB,’ he/she may use this information under ‘Associated Signs/Symptoms.’”

This statement is available in the EM Help Center as “E/M Weekly Tip: History of Present Illness (HPI) - Negative Findings/Complaints.”