Wiki HPI elements

[Kedami38]

I have a question I was coding a admission and discharge same day observation E/M and I had trouble with getting 4 elements in the HPI

Chief Complaint: shortness of breath, cough
History of present illness: 69 year old male with past medical history of hypertension, atrial fibrillation, COPD presented to emergency room was complaints of worsening shortness of breath for the last couple days. Denies any chest pain medicine nausea no vomiting. On admission in emergency room stay chest revealed bronchiectasis, scattered mucous plugging, emphysema.

I had worsening as either quality or severity, last couple days for duration and shortness of breath, chest pain for associated sign and symptoms

My auditor states that I should use shortness as quality..........I'm having trouble understand this as it is not a character of a symptom because it is actually the symptom and breath is not a symptom. My question is can this be used as quality?

 

[thomas7331]

I've been coding and auditing E&M levels for many years now, and I'll tell you that to be honest, details like this don't really matter. The auditing guidelines for how to determine the level of a history are just that - guidelines. They aren't regulations or concrete rules that can tell you exactly what a level should or should be, or exactly how many points should be counted or which exact words in the document qualify or do not. So you have to use your judgment on these things, and be prepared to be able to defend your choice if an auditor arrives at a different conclusion. And no two auditors will always arrive at the same thing, especially when it comes to E&M coding. So there isn't a rule that says that 'shortness' can or cannot be used - your argument that it is part of the symptom is a valid one (and I would lean that way too), but the auditor's argument is also valid. Neither is right or wrong, and I have always advocated that something like this should be called a coding 'variance' rather than an error. Because truthfully, in all my experience with payer audits, it never comes down to this. Payers will down-code an E&M service if the level is clearly wrong or if it is unreasonable for the type of problem that the provider is treating, but they will not spend their time arguing back and forth with providers over what words do or do not qualify as an 'element' or a 'point' because they (at least in most cases nowadays) understand that this kind of exercise is not an effective use of the resources that should be devoted to providing medical care.

Fortunately, starting next year, if the CMS rules go into effect, we'll hopefully not have to worry so much about these minor details and grey areas.

Sorry for the long answer, and I know it's probably not much help, but that's my take on it.

 

[twizzle]

I've been coding and auditing E&M levels for many years now, and I'll tell you that to be honest, details like this don't really matter. The auditing guidelines for how to determine the level of a history are just that - guidelines. They aren't regulations or concrete rules that can tell you exactly what a level should or should be, or exactly how many points should be counted or which exact words in the document qualify or do not. So you have to use your judgment on these things, and be prepared to be able to defend your choice if an auditor arrives at a different conclusion. And no two auditors will always arrive at the same thing, especially when it comes to E&M coding. So there isn't a rule that says that 'shortness' can or cannot be used - your argument that it is part of the symptom is a valid one (and I would lean that way too), but the auditor's argument is also valid. Neither is right or wrong, and I have always advocated that something like this should be called a coding 'variance' rather than an error. Because truthfully, in all my experience with payer audits, it never comes down to this. Payers will down-code an E&M service if the level is clearly wrong or if it is unreasonable for the type of problem that the provider is treating, but they will not spend their time arguing back and forth with providers over what words do or do not qualify as an 'element' or a 'point' because they (at least in most cases nowadays) understand that this kind of exercise is not an effective use of the resources that should be devoted to providing medical care.

Fortunately, starting next year, if the CMS rules go into effect, we'll hopefully not have to worry so much about these minor details and grey areas.

Sorry for the long answer, and I know it's probably not much help, but that's my take on it.

Agree totally with Thomas. Guidelines are there to lead you along the straight and narrow up to a point. I too have audited E/M for a few years and sometimes you have to really stretch the verbiage to get to the level you need to be at. We, as auditors, are trying to help the provider, not hinder them and by utilizing an adjective such as 'shortness' to get an HPI element is absolutely okay. If you're consistent and can defend your decisions then you're in a good place.

 

[kdlberg]

Don't forget location. The problem is with the respiratory system. So that's location, severity (worsening), duration, and associated signs and symptoms. "Shortness" isn't really a quality. "Shortness of breath" is treated as a complete word, because you can't separate it out and have it make sense. (Quality, you can take the word away and still get the point.)