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Severity HPI

  1. Default 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?

  2. #2
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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.
    Chelle Johnson, CPC CPMA CDEO CEMC CPCO CPPM AAPC Fellow
    Billing/Coding/Credentialing/Auditing Coordinator

    20+ years experience in Medical Billing and Auditing

  3. #3
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    Default Severity HPI
    Quote Originally Posted by KaylaRieken View Post
    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.

  4. Default
    Medical Billing
    Thanks guys!! I knew I was trying to stretch too hard!!!

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