Severity HPI

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Patient has kidney stones and in the HPI physician says she does describe some urinary frequency, but drinks quite a bit of water throughout the day. Can I use some as severity?
 

Chelle-Lynn

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I personally would not classify "some" as a level of severity. With that said, there is no guidance indicating what wording can be used to support severity. Therefore, any word or phrase that conveys the severity of the condition can be credited. Common examples expressing severity that would meet this standard; mild, moderate, severe, unbearable, worsening, etc.

When it comes to HPI it can be a judgment call on the part of the coder. I always advise to level based on what you would feel comfortable defending before an auditor when the definitions are imprecise.
 

twizzle

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Patient has kidney stones and in the HPI physician says she does describe some urinary frequency, but drinks quite a bit of water throughout the day. Can I use some as severity?
I personally would not accept 'some' as severity. If the provider had just documented 'urinary frequency' you wouldn't have any less information than 'some urinary frequency'....... it's basically saying they have it, not how badly they have it.
 
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