HPI Question - medicine provider

dballard2004

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I have a question regarding HPI that I would like opinions on, please.

I am auditing for an orthopaedic/sports medicine provider, and when patients present to the office to be seen, they fill out a form where they note the reason they are seeing the doctor, what they have done to date for the problem, their past medical, family and social histories, etc.

On this chart in question, the patient notes on this form info regarding the chief complaint that would be considered HPI (i.e., modifying factors, associated signs/symptoms), but the provider does not mention this info in his dictated HPI. For example, the patient outlines what they are doing to date for the chief complaint (i.e., modifying factors) and other signs/symptoms that are occuring with the chief complaint, but the provider fails to mention any of this info in his dictated HPI.

In the chart, the provider does acknowledge that he has reviewed this form.

My question here is, can I use this info supplied by the patient as HPI even though the provider omits it in his dictated HPI?

I have read the E/M guidelines and they seem to indicate that the provider acknowledging the patient form really only applies to the ROS/PFSH section of the history.

Thoughts?

Thanks. :)
 

LLovett

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The provider has to get the HPI

I wouldn't count it. If the provider can't say they reviewed HPI done by the MA then why would they be able to do that when it was done by the patient?

I know there are some posts that say this is ok as they have been audited and were not dinged for it. Personally I wouldn't take that chance.

http://www.wpsmedicare.com/part_b/resources/provider_types/evalmngmntqahistory.shtml

Q 19. Who can perform the History of Present Illness (HPI) portion of the patient's history?
A 19. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.


Hope this helps,

Laura, CPC, CPMA, CEMC
 

rthames052006

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I agree with Laura on this one. Had the provider documented what the patient wrote down on that form, it could be used but since the provider did not, I would not count it as HPI.

It's ashame too because it seems the patient provided a very good/detailed HPI by completing that form.

Sounds like you (Dawson) have some provider education you can count on doing in that practice :)!
 

dballard2004

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Let's add another layer to this.......I am on the fence regarding the history level between a PF and an EPF. In order to obtain an EPF history, the provider must have 1-3 elements of HPI, a clinically pertinent ROS, and no PFSH.

Here is the issue..... the patient presented with a knee injury due to a fall. This provider has 1-3 elements of HPI, but I am torn regarding the ROS. In the note, the provider mentions that the patient has no allergies. I know that review of allergies can be counted as ROS under the Allergy/Immunologic category, but is an allergy review really clinically pertinent to a knee injury?

I think not, but I would like others opinions. Thanks.
 
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MnTwins29

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Your question raises another

Dawson, your question on this makes me wonder if the items listed in the ROS NEED to be clinically pertinent to the CC or final diagnosis. How many times do we count ROS items for any system, regardless of what the MD's specialty is or whether the system is relevant to the CC? I have never heard of requiring systems reviewed be pertinent to the CC - therefore, I would include the allergies in the ROS.

Of course, I could be wrong, but that is what I believe.

Thanks.
 

dballard2004

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Lance-thanks so much for your response. I appreciate your insight as always. In referencing the '95 and '97 E/M guidelines, an expanded problem focused history is defined as a brief HPI (1-3 elements), a problem pertinent ROS, and no PFSH. The guidelines state that a problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

Now my intrepretation of this may be off, but I intrepret this guidance to mean that the one ROS required for an expanded problem focused history must be clinically relevant to the HPI in some way. I suppose one could make the argument that all ROS is relevant to the HPI in some way, but I am trying to be careful here to make sure that I am auditing this provider fairly.

I went ahead and counted the allergy review as part of the ROS for this encounter because I thought more about it and decided that an allergy review could be relevant at some point to this chief complaint of a knee injury.

I appreciate all replies here and to all for being patient with me as I sort through the complexities of E/M coding.

Thanks.
 

ollielooya

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This has been a very educational and enlightening thread. So, if I understand this correctly the allergy review will meet the criteria for EPF yet the issue is with the word ---> pertinent.
So, I guess the question remains to be asked (and may require a clinical perspective?) how is it deemed pertinent?
I love the complexiities and art of this subject!

Suzanne E. Byrum CPC
 
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1-3 elements of HPI & problem pertinent ROS

Let's add another layer to this.......I am on the fence regarding the history level between a PF and an EPF. In order to obtain an EPF history, the provider must have 1-3 elements of HPI, a clinically pertinent ROS, and no PFSH.

Here is the issue..... the patient presented with a knee injury due to a fall. This provider has 1-3 elements of HPI, but I am torn regarding the ROS. In the note, the provider mentions that the patient has no allergies. I know that review of allergies can be counted as ROS under the Allergy/Immunologic category, but is an allergy review really clinically pertinent to a knee injury?

I think not, but I would like others opinions. Thanks.
First, Allergies is ALWAYS problem pertinent because you may be prescribing medication and need to know if there are any allergies. Additionally, swelling may be the result of allergic reaction vs injury, so again, problem pertinent.

Second, since you need 1-3 elements of HPI, I stop counting at ONE and see if either of the other two elements might be able to be counted as ROS. For example: patient twisted left knee playing basketball; same knee he had surgery on last January.
I would use the last part of this statement as ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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