Wiki Negative responses in HPI

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Hi all,

I am in a debate with a fellow coder outside my office and we need a decision breaker.

Do negative respnses count in the HPI?

Example:

Pt has been asymptomatic, or lesion has not grown, or there is no pain associated with the growth... I can go on and on but I think you guys will get the idea...

Thanks!

dscoder74
 
they absolutely count. if documentation states "no pain associated w/growth" then that counts as 1. The dr. had to address this and he gets credit for the work done. Just because the growth didn't grow anymore, doesn't mean the dr. didn't address it. Just as ths statement "asymptomatic" gets credit too, because the dr had to do something to come up w/the correct answer.
 
Agree ... if specific

I agree that negatives can count in the HPI (or the ROS) - as long as they are specific. The examples you gave would definitely count.

But I've actually seen a physician document "HPI: negative" or (more often) "ROS: negative" ... well ... why is the patient here?! (I'm in a surgeon's office - we don't do preventive.) That kind of statement counts for nothing.

F Tessa Bartels, CPC, CEMC
 
Oh my gosh!

Thanks everyone, that was very helpful....I had an instructor that taught me when it came to negatives in the HPI it did not count. I am a little shaken up for all of the dictation that I have coded where I did not count the negatives in the HPI. The instructor stated you can only use negatives in the ROS and exam.

Should I seek counsel from our local Medicare carrier or is this pretty universal?

Thanks,

dscoder74
 
I would recommend contacting your local carrier for their view. Your scenario was an issue for me some time ago. When this surfaced, I presented this question at our local Medicare E/M seminar. Our carrier does allow negatives. Don't get too shaken up...carriers change their policies constantly. It's a cat and mouse game. Trying to keep up with them can be a job in itself. If your carrier does allow for this type of documentation, meet with your providers and move on.
 
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