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History Level??

  1. #1
    Location
    Harrisburg, PA
    Posts
    11
    Default History Level??
    Exam Training Packages
    Please help me. I am trying to code out this history, it is a subsequesnt hospital visit...

    " Her chief complain today was "this food is making me choke." This is a 64 year old morbidly obese white female who was admitted with respitory failure, acute on chronic. When seen today she was sitting out of bed in her chair attempting to feed herself with some modified utensils. She staes the the consistancy of the food makes her choke, and she is not at all happy about that. SHe has no trouble breathing. She has no nausea or vomiting. She has no pain issues. She has no cough or chest pain. The rest of the review of systems was negative apart from what was mentioned above. Her past medical, surgical, social, and family history were reviewed from the H&P which was dictated on July 17, 2010. No change to the same.

    Can you please help me break this down. It is just giving me some severe hangups. Any help on the break down in much appreciated.

    Thanks!
    Ashley

  2. #2
    Default Help me please
    Hi Ashley, I was told to use 99233 since there was past history, social, and family history were reviewed.
    Last edited by perkins; 08-05-2010 at 11:53 AM. Reason: wrong infomation

  3. #3
    Default History Level
    Hi Ashley, I m not sure, but I would use 99232.

  4. #4
    Default
    This is comfortably EPF, since it is inpatient it doesn't require the PFSH but they did list it as well. You could say it is detailed but I think that might be pushing it.


    Her chief complain today was "this food is making me choke." This is a 64 year old morbidly obese white female who was admitted with respitory failure, acute on chronic. When seen today she was sitting out of bed in her chair attempting to feed herself with some modified utensils. ContextShe staes the the consistancy of the food makes her choke,Mod Factor and she is not at all happy about that. SHe has no trouble breathing. Associated Sign/SymptomShe has no nausea or vomiting. She has no pain issues.Severity but this might be stretching it She has no cough ROS Respor chest pain ROS CV. The rest of the review of systems was negative apart from what was mentioned above. Her past medical, surgical, social, and family history were reviewed from the H&P which was dictated on July 17, 2010. No change to the same.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

  5. Default
    I have to disagree on one portion. Anything that is denied, does not have or stated as no (any negative) is a ROS. A symptom that the pt does NOT have can not be counted as an Assoc S&S. All of the below is ROS

    "She has no trouble breathing(Resp ROS). She has no nausea or vomiting (GI ROS). She has no pain issues (Neuro ROS). She has no cough (Resp ROS) or chest pain (CV ROS)."

    I would also be very hesitant to code a 99233 (detailed exam and high complexity MDM) but then we don't know what was documented in the rest of the note.

  6. #6
    Default
    Sbicknell,

    Can you please provide documentation to support pertinent negatives can not be counted as HPI elements?

    Thanks

    Laura, CPC, CPMA, CEMC

  7. Default
    There are numerous postings on the net on the HPI elements and I have never found one that says what a patient does not have can be counted as an Assoc S&S

    I know there were some seminars a while ago that it was being said the Assoc S&S could be stated as a negative. And I disagree and would like to see their support for that statement

    If the CC was chest pain, denies SOB. I would not count the "denies SOB" as an Assoc S&S. The Assoc S&S is to identify what else is going on at the time of the CP. So if the patient does not have something (nothing eles is going on) then there is nothing to be "Associated".

  8. Default history
    Hi, I've found that the e/m scorecard on Highmark's web site is very helpful. Go to their web site and click on e/m training and print e/m score cards. The history portion states for a complete ROS their must be 10 or more systems, or some systems with statement "all others negative". You have extended HPI, so I would code this comprehensive. Suzanne

  9. Default
    Be aware that the statement "all other negative" for ROS is not accepted by everyone and is specifically rejected by Texas Trailblazer

  10. Default history
    Thank you for the info....I was going by CMS guidelines.

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