Wiki Exam Details used as HPI elements

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MandyFlagg

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Hello again,

I have a dilemma. I am being told to use exam details to get credit for HPI elements to bump the consult level up. I am pretty sure I have read somewhere that you cannot do that because the exam is actual findings documented after the HPI would be documented. Can anyone help me with this and/or tell me where to find this documented?

Thanks a bunch!
Mandy
 
HPI is NOT exam or vice versa

The HPI is a "history" ... explained by the patient on prompting by the physician. This is SUBJECTIVE information that describes the nature of the complaint that brings the patient to the office. For example: How long has it been present? Does anything make it better or worse? How bad is it? What other symptoms go with it?

The exam is a record of the physician's findings on examining the patient. This is OBJECTIVE information. For example: BP 120/82. The lungs are clear to auscultation. Heart is RRR w/o MRG. Abdomen is soft and tender w/o hepatosplenomegaly.

That being said, I've seen physician's record elements of history under the "exam" heading ... so I'd have to see the actual note to tell whether you've been given accurate guidance in this particular case.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
The patient is being seen for wound rounds, they give a few things regarding this in the HPI but I am being told to use the measurements and the description (drainage color, etc) from the exam (what they observed) from the exam as HPI elements like for severity.
 
Are you being asked to use the info for both HPI and exam?

I agree with Tessa, and based on your example this sounds like exam to me, not HPI.

Laura, CPC, CEMC
 
no they want me to pull that info up to use to increase the HPI level to raise the code, it is crazy if you ask me but they will not take anything from me they have to have it in writing that you cant do that. I already used the subjective vs objective thing.
 
Ok, next question, what kind of exam are you left with if you do pull those elements out to be used as history?

Consults are 3 of 3, the doctors I have in infection disease that do wound care, do very limited exams. If I pulled exam elements up to beef up the history (which I am completely against since it is wrong) my level of exam would tank and it wouldn't do any good to have a higher level of history anyway.

As far as being in writing, just give them the documentation guidelines. History is obtained from questioning the patient or other appropriate source. If the documentation states something like "3 cm wound, no purulent drainage, located on the lateral aspect of the left foot" this most likely was not obtained by questioning the patient but in fact during exam.

It sounds like the providers need further education if their documentation is truly lacking or the powers that be need to realize what they are doing is considered fraud.

Laura, CPC, CEMC
 
that is EXACTLY what I am saying, they just don't listen to me this person is a NP who just went and got her CPC-P and now everything I say does not matter, I just (on saturday) took my CEMC, don't feel that great about it but did, and I am hoping that will make a difference. These NP's do SNF subsequent billing so they have other exam bullets to be able to use that is just a small slice of what they have written, and being that I am coding the encounters I do it the way I believe is right, but then get called on the carpet about it.
 
Inpatient Subsequent Codes

Are you talking about inpatient subsequent visit codes? 99231-99233?

What you are looking for is an INTERVAL history ... what has happened since the last time the doctor saw the patient (yesterday, two days ago .. whenever)

Sounds like your "advisor" wants these to be 99233 which requires 4 elements of HPI, plus 2-9 ROS reviewed, plus an interval pertinent PFSH.

Subsequent hospital visits only need 2 out of 3 key components ... can you use MDM and exam? Of course for 99233, MDM should be HIGH ... this may or may not be the case for your actual scenario.

While I see notes that are all jumbled up and occasionally an element of history will be at the bottom vs at the top, I still cannot double dip. As Laura said, if you took the size of the wound or color of discharge from your exam and counted it as severity, then you can't count that as part of your exam.

Might be helpful if you could post even one of these notes as an example.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Is this still relevant in 2019?

My team and I have been given the same instruction - to pull HPI from the exam, because the HPI says "see wound assessment" but the wound assessment is captured during the exam.
SOAP, still applies and this is why we cannot pull HPI from the exam? HPI = history?
 
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