HPI Element "denies N/V"

[tboback]

I audit E/M visits and I have a re-evaluation from a provider who is using "Denies Nausea/Vomiting" as the Associated Signs and Symtpoms.

I believe this is NOT a valid element.

Any thoughts or souces that I can use to support this NOT being a valid element?

 

[tboback]

HPI Element "denies vision changes"

Same provider has another re-evaluation and using "denies vision changes".

PLEASE need your help.
I need too respond asap and need to have proof or something to reference saying that this is NOT an acceptable element for Associated Signs and Symptoms for HPI.

**PLEASE NEED YOUR HELP**

 

[LLovett]

I suppose it may depend on who the carrier is but as long as it is pertinent to the CC this does qualify as an HPI element. Pertinent negatives get the same credit as positives.

Examples
CC: Abd Pain
Abd pain for 2 days, no N/V, pain is described as sharp in nature.

CC: Eyes watering
Both eyes have been watering for the past 2 weeks, patient denies vision changes, does take meds for seasonal allergies.

Now if it has nothing to do with the CC then it would not count because it would not be pertinent.

Examples
CC: Ankle pain
Left ankle hurts, twisted it while playing football 2 hours ago, no N/V or vision changes.

Since these have nothing to do with the CC they would just count as ROS not HPI.


Laura, CPC, CPMA, CEMC

 

[tboback]

Thanks Laura!

The CC is auto or WC injury and it's the initial ER visit. I believe the injury was to the arm, but with that being said and this is the initial ER visit I would allow for it to be used as HPI.

Your thoughts?

 

[FTessaBartels]

Trauma

It would be prudent for the ED physician to ask certain questions to evaluate for potential head injury or internal injury not evident on first glance.

While I'd be more inclined to list these for ROS, I could probably make an argument that these negatives might count for HPI if the chief complaint is "trauma, S/P MVC"

Hope that helps.

F Tessa Bartels, CPC, CEMC