Wiki Is "pain" a Quality in HPI?

[tag60]

In our internal audits, the auditor is counting the word "pain" as a Quality element in the HPI. In all the examples I've seen from various sources, including CMS and various E/M courses I've taken, I've never come across "pain" as a Quality. Throbbing or burning pain, yes, but just pain?

Recently she counted "palpitations" and "infection" as Quality elements. I'm curious if others agree or have learned to count these as such, and if so, can you cite a source?

Thank you!

 

[Pathos]

Whenever I get questioned regarding E/M visits and audits, I always go back to my trusted sources. While CMS doesn't always provide clear-cut answers/guidelines, in this case I think they hit pretty close to the mark.

According to their E/M Guidelines on HPI:

"History of Present Illness (HPI) HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

• Location (example: left leg)
• Quality (example: aching, burning, radiating pain)
• Severity (example: 10 on a scale of 1 to 10)
• Duration (example: started 3 days ago)
• Timing (example: constant or comes and goes)
• Context (example: lifted large object at work)
• Modifying factors (example: better when heat is applied)
• Associated signs and symptoms (example: numbness in toes)

The two types of HPIs are brief and extended.
A brief HPI includes documentation of one to three HPI elements. In this example, three HPI elements – location, quality, and duration – are documented:

• CC: Patient complains of earache
• Brief HPI: Dull ache in left ear over the past 24 hours

An extended HPI:

• 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities
• 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions "

Based on what I see from CMS and what you are presenting, I would probably agree with your thinking. "Pain" in itself is not enough for me to consider towards any HPI elements, as I would want a descriptor to follow. I am also a bit uneasy to use "palpitations" or "infection" as a describing quality of the Chief Complaint, however since this information is taken out of context of the chart, this can be a hard call to make.

Hope this helps somewhat. Perhaps go half-way and ask the auditor of her reasoning behind using the above descriptors and her references to back these up?

 

[KellyLR]

Sounds like the auditor is making the best out of the documentation to justify a coder's coding. If the auditor is doing this to upcode a reported coded encounter at a different level, then there is an issue that needs looking into.

 

[Mayzoo]

Depends on where they were trained from my experience.

I spoke with a certified E/M coder who insisted that the doctor stating the patient picked up ted hose or OTC meds from a pharmacy was a modifying factor even though no outcome of those interventions was mentioned (all that was stated was the pt bought ted hose....not even a mention if they had tried them on). This person was not AAPC or AHIMA trained/certified for E/M coding. I would not count that as a modifying factor unless an outcome of some kind is noted.

I also would not count pain as quality unless an adjective is attached; it could be location if it states where the pain is. ETA: Palpitations can be used as ROS for cardio (even if only mentioned in HPI), but not in the HPI as quality without an adjective. Infection can be used in the HPI only if they list a location with them.