What about if the provider basically documents his HPI under the treatment plan? I have one provider where he addresses everything in detail under the Treatment plan, but some of these things are not even mentioned in the HPI or don't have enough detail. Is this acceptable? I have reiterated numerous times to indicate all problems/concerns in the HPI but for some reason the LVN puts in the HPI & the provider will go into extreme detail under Treatment/Plan. Even on conditions never mentioned in the HPI. I have seen a couple posts stating it does not matter WHERE in the note it is documented as long as it is documented as addressed by the provider..is this accurate?No they would not count. The provider would have to document in the HPI that he/she is also evaluating those chronic conditions. Per the AMA, "a problem is addressed or managed when it is evaluated or treated at the visit by the provider reporting the service. This includes consideration for further testing or evaluation". The chronic condition(s) may, however, play a part in the level of Risk. Ex: if a COPD patient is being seen for a severe upper respiratory infection, chances are the provider is going to take their COPD into account as it may be affected.
Great thank you!! i definitely agree & just wanted another coder's input! you have been so helpful!If I were in your shoes, I'd go by the HPI. I know exactly what you're talking about in regards to how they are documenting - I saw that trend on a review once and it about drove me crazy! So I'd go back to what you know as a coder where we are instructed to use the HPI as the basis for the visit. Like you mentioned, it is true that sometimes the HPI and other elements can be spread out within the note so definitely be on the look out for that, but go by how the provider addresses the problems. If he says the patient is there for a follow up on issue A and B, go with those, even if he lists three other conditions as stable. If there was no evaluation or recommendation, I would not count them.
Yep, doesn't have to be specified in the HPI. My providers never list everything in there. The assessments, however, do indicate the necessary documentation to show the problems were addressed.According to the AAPC webex I took last week, the information doesn't have to be in the HPI, it can be listed in the assessment and plan, but it has to be clear in the a&p how the provider knows the condition is stable. They cannot just write Diabetes-stable, continue medicaition. It needs to be clear how they know the chronic condition is stable.
I was also thinking perhaps it would count if it is addressed even though it is not in the HPI. So it's almost like there are two HPI's in this specific provider's notes because his nurse will put in the HPI at the top and then he will go under Treatment & document his HPI as well as findings so i'm just not 100% sure on how to go about this. I usually audit the note in chronological order so by using the MDM chart, i would basically be having to go back to the # of problems addressed & redo the whole audit. Does that make sense? If the provider is putting in his own HPI, i don't see why he can't put that in himself at the top vs having a nurse do it and then it appears like there are two HPI's in the note. I'm just very frustrated with his flow i guess!Yep, doesn't have to be specified in the HPI. My providers never list everything in there. The assessments, however, do indicate the necessary documentation to show the problems were addressed.
Great thank you so much for your feedback!!I wouldn't get hung up on actual HPI "sections". Like saddie2k said, sometimes providers don't list detail in the place we would usually find it. But the provider needs to somewhere in the note confirm the reason for the visit and what conditions are being treated. Some documentation styles don't allow us to go in perfect order of history, exam, MDM like we are taught to do.