Wiki E/M Consult HPI

[swyty]

Does anyone know where I can find any publications which state what information can be used to count the elements for the HPI? I was told yesterday I could count info that is NOT related to the reason the pt is being seen.

Example: Consult for Pelvic Lymphadenopathy.
Info under HPI: Pt has pelvic lymphadenopathy. Recent hospitalization for chest pain with no CT findings.

I was told I could use the elements from the hospitalization for the HPI which made absolutely no sense to me because this has nothing to do with the pelvis!! If someone has any info to help, I would greatly appreciate it.

 

[FTessaBartels]

In your example

I agree with you for this example ... I would count:

HPI:
Location: pelvic
Quality: lymphadenopathy

Past Med Hx
Recent hospitalization for chest pain

While you CAN use elements from a recent hospitalization in an HPI that holds true only if it's directly related to the presenting problem. So, for example, if the notation had been "during recent hospitalization patient complained of pelvic pain" then I'd count it for an assoc sign/symptom (and if we knew what "recent" meant - i.e. had an actual date - I might count duration as well)

Hope that helps

F Tessa Bartels, CPC, CEMC

 

[swyty]

Thank you for your reply. I was thinking the same way you are and the person that told me this is a certified E/M coder/reference for the company I work for but she couldn't give me any anything to prove she was correct. I just refuse to believe her until I can find some documented proof to support what she said.

Thanks again for your input.

 

[RebeccaWoodward*]

Ditto here... If we were allowed to use information not pertinent to the CC, we could always achieve a history higher need medically necessary.

The documentation of each patient encounter should include:
o Reason for the encounter and relevant history

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

My carrier's statement.....

*A patient's history* is made up of the following elements:
- Chief complaint
- History of present illness
- Review of systems
- Past, family, social history
* And the extent to which these elements are performed —according to patient's needs yield the different levels of history.