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Part B Insider (Multispecialty) Coding Alert

History:

Make Sense of a Single Paragraph

Published on Wed Dec 17, 2003 Print Friendly and PDF PDF

Learn to dissect jumbled history into three categories

Many coders expect the physician to separate notes carefully into history of present illness, review of systems, and past family and social history to make it easier for them to construct the documentation.
 
But that's not how physicians are trained to take a history, and coders should be used to sorting information into the three categories themselves, says Joanne Steigerwald, senior consultant with the Wellington Group in Cleveland.
 
"Most coders and auditors would like it in nice separate paragraphs,"  Steigerwald says. "It not only isn't going to happen, it shouldn't happen," because that's not how good physicians take a history, she claims. Only if the physician also notes an unrelated problem should he or she add a separate paragraph.
 
So coders should be able to pull the HPI, ROS and PFSH out of the single paragraph that a physician may write down for history. To this end, Steigerwald encourages coders to take courses in medical terminology, pathology and anatomy. "Once they've done that, it'll be a lot easier to pick out those pieces because they'll know what they're talking about."
 
For example, if the physician writes down that the patient appears to have pylorus spasms, the coder should understand that the pylorus is the ring of muscle at the base of the stomach, and that pylorus spasms often accompany projectile vomiting. "They have to know enough about what they're doing to recognize that even if it's not in the paragraph where they'd like it to be, it's still what it is and give the doctor credit for it," Steigerwald adds.

Get more details for HPI

It's not enough to state the patient's present circumstances as part of HPI, says Laura Talbert with Shore Billing & Management in Allen, Md. The doctors "need to get more details." These can include:

 

  •  location of pain or sensation, quality (such as stabbing, sharp, radiating or throbbing)
     
  •  duration of symptoms
     
  •  timing (such as continuous or only in the mornings)
     
  •  context in which the symptoms first manifested
     
  •  modifying factors such as an improvement when the patient sits down or uses heat or ice
     
  •  associated symptoms such as chest pain associated with shortness of breath.

    These factors are based on how the physicians learn in medical school to identify a problem, Steigerwald says.
     
    For a brief history, the physician needs to have one to three factors in HPI, and for an extended history, the physician needs four or more, Talbert says. For a patient with multiple complaints, you don't necessarily need one to three pieces of history per complaint.
     
    Many physicians don't add enough information under HPI for an extended history, says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J. They don't have prompt sheets to remind them to get more information, and they don't realize until later that they only ended up with three items under HPI.

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