See any HPI elements here?

[AmandaW]

CC: Respiratory failure.



INTERVAL HISTORY: Patient remains unresponsive and chronically ventilated via tracheostomy.

 

[teresabug]

naw.... not a billable E/M.

 

[Cynthia Hughes]

How about "chronically ventilated via tracheostomy" as duration or context for the respiratory failure and unresponsive as an associated sign or symptom? Also, this is likely a subsequent visit, so one cannot assume that there is no reportable service.

 

[AmandaW]

Sorry, I should have included that it is a subsequent hospital visit...not initial.

 

[AmandaW]

This was a case on E/M University and the answer analysis gave no points for the HPI and I didn't understand why. The Dr/CPC said this in response to my question about why it would not be 'brief'? .......

Which HPI elements are present? You would need one to three to qualify for a brief HPI. I don't see any. Did I include one by accident? PJ. .....



I was thinking about "Unresponsive" being an 'associated sign or symptom' also Cynthia because it is associated to the presenting problem...or 'severity' because I think it describes how bad off the patient is -some examples could be pain is a 9 out of 10 or feeling well or ok...in this case patient is just flat out unresponsive which describes how bad off the patient is.

And modifying factor for "chronically ventilated via tracheostomy" due to that statement explaining what is being done to help or alleviate the problem - Respiratory Failure.

I'm waiting for his reply on the forum on the E/M University website -just wanted to see if anyone thought what I thought....

 

[Tiger]

Location.................................lung
Duration.................................chronic
Modifying factor.......................ventilated via tracheostomy
Associated sign & symptom.......unresponsive


I think it can broken down this way. Let me. Know what you think.

 

[OCD_coder]

How is the patient going to answer history questions if they are unconscious?
and have a trach tube. Not all patients can vocalize with trach tubes in.

1995 DG:
DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Just an alternative thought, but I'd hate to penalize the provider when they can't obtain information.

 

[AmandaW]

OCD_Coder, do you think the record 'describes the patient's condition or other circumstance which precludes obtaining a history.' ?

 

[mcarrillo]

Hi,
I agree with OCD_Coder. I have known the guidelines mean that when a history can't be obtained, the Dr has to specify why or what it is that's preventing him/her to obtain it. A simple note stating "history unobtainable" does not suffice. Clearly in this statement Patient remains unresponsive and chronically ventilated via tracheostomy explains why the provider is unable to attain this and therefore should be adequate for the history.

Just my opinion.

 

[AmandaW]

I believe so as well. I'm still waiting on his response as to why he finds there to be no elements at all...

 

[jvanek82]

I believe so as well. I'm still waiting on his response as to why he finds there to be no elements at all...

I would say that maybe he is finding there to be no elements for an HPI because that information is supposed to be collected from the patient's statements as to what is going on for that encounter. So, basically the HPI you are looking at is the physician's statement.

However, per CMS guidelines (1995 DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.), I agree with OCD_coder and mcarrillo that the statement does show why the physician is unable to collect the history and therefore should be sufficient documentation to support a history for this encounter.

 

[AmandaW]

Thanks so much!