Wiki HPI in the MDM?

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sparkles1077

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Fellow Coding Professionals,

One of the auditors I work with indicated that if we can not find enough HPI elements in the HPI portion of the note, but find it elsewhere (e.g the duration of the illness is found in the MDM) that it can be counted in the HPI. This is because we as coders must give as much credit to the provider as possible. Has anyone else heard this and if so, would you happen to have a resource?

Thank you,
Diana
 
I'm not sure I can point to a specific reference, but I know what you mean. I will mention that nowhere that I know of does it say that the documentation must fall under specific headings...the DGs tell us what the history is and what it entails, for example, but not that it must reside under a heading labelled "HPI". Some providers use a SOAP (subjective, objective, assessment, plan) note, others use CHEDDAR (chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral), but no doctor that I've ever encountered documents in a way that aligns with my audit tool (wouldn't that be nice?!!)

In an EHR, usually the key components are located where we like to see them: HPI under HPI, ROS under ROS...you get the picture. In a dictated note, or in texted fields, information is being input by the provider in a format that makes sense to him. We'd like it to all match up, but that isn't the reality. Many of my providers will do a 'recap' of the presenting problem in the assessment/plan, thus providing HPI elements under a different heading. Sometimes, particularly in a hospitalists' handwritten note, that's where you discover the chief complaint, depending on their documentaiton style.

So as long as it's documented within the note, is medically necessary and relates to the chief complaint, you can count it towards your key components as appropriate.
 
I agree as long as it is in the note it can be counted. It does not need to be seperated into categories or bulleted to be counted.

:)
 
When you say the HPI is found "in the MDM" I assume what you mean is that it's toward the end of the note, the part where you normally find the assessment/plan, formulation, etc -- based upon which the MDM is calculated. Those are just headings... technically the provider is not required to even label them. They could write one long paragraph with no punctuation. You as the coder/auditor would have to determine what is history, what is the exam, and what is the MDM.

I commonly see MDM elements mixed in with the exam (lab results, x-rays) or history elements in the assessment/plan. If it's documented, give them credit -regardless of where it is in the note.
 
How about for location?

What if the the CC and HPI just say "lesions", yet Assessment/Plan says "chest and upper l back"? Can I use that as location for the HPI?

Thank you!
 
Yes - like Mike said in the previous post, if the physician documented it, give credit for it, regardless of where on the note the documentation is located.
 
I have found this discussion to be an eye opener. I had understood that HPI was the patient's description of the complaint, while the Impression & Plan is the provider's assessment.

Are you all certain that we can get HPI points from the Impression and Plan?
 
Catchthewind - that's exactly why I was asking. If the location is found under the Assessment/Plan I would think it's more of a part of the exam or A/P than the HPI which is what the patient is supposed to be providing!
 
CatchTheWind said:
Any takers on answering whether the HPI must be credited only from the patient's statements?

I, for one, say that it does!
Click to expand...

How many patients will state "I am here for a follow-up of left breast cancer, ER/PR +, stage III, metastatic to my brain for 3 months. I'm on chemo with no associated signs or symptoms?
If the physician only documented specifically what the pt stated we may never get a complete HPI. As above it gives me location, quality, severity, duration, associated S/S.
Just my 2 cents.
 
HPI is historical and should be based on interviews with the patient or other representative of the patient.

Chief complaint is generally in the patients own words, otherwise the HPI is based on the patients answers to specific questions, not necessarily how they said it.

For example when asked what is going on, the patient may state "it feels like I'm peeing fire" but the provider actually documents "patient complains of a burning sensation while urinating".

For providers that lump all elements in a long paragraph it can get messy trying to distinguish what is what. I tend to lean towards the conservative side and look at it from the perspective of what work was done to generate each element.

History portions are based on questioning and reviewing previous documentation. Exam portions are based on action(s) (for lack of a better term) performed by either the provider or the patient. The MDM is based on the assessment and plan which is the summary of the providers findings thru history and exam along with their action steps.

Once they start formulating their assessment and plan I generally no longer consider any of these elements valid for history of present illness. I say generally because there always seems to be some instance that will make me change my mind.

Just my take on it for what its worth,

Laura, CPC, CPMA, CEMC
 
Hpi info found in the mdm section

I realize this is an old thread but I just happened to come across it and wanted to reply. I believe someone replied that they believed the HPI could only be the patients words and because of that, HPI info could not be gleaned from somewhere else in the note. It is my understanding that only the CC is supposed to be the patients own words, stating why they are there to be seen. Most of the HPI info does come from the patient after the provider has asked the pt various questions, (i.e. how long has this been going on, how severe is the pain). But a provider could also document the status of 3 chronic's and simply say for example, the pt has HTN that is stable on Metoprolol 25mg 2xday. The provider can also document that a pt had a recent CT done which showed splenomegaly -- that would be considered context, but those words did not come from the patient. I have many providers who might state under the HPI heading that the pt is in for f/u lung cx and is doing well with no complaints -- but down under his MDM heading, he will further elaborate to give several more HPI elements and then he will lead right into this plan. We are allowed to pull what we can from where ever we can, as long as we aren't double dibbing.

Sharon H., CPC, CGSC
 
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