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Chief Complaint and HPI-I realize that

  1. #1
    Location
    Overland Park, KS
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    1,166
    Default Chief Complaint and HPI-I realize that
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    I realize that the chief complaint and the HPI are two separate components, but can you count elements in the CC in the HPI?

    For example, the following is documented....

    CC: UTI, symptoms present for 1 day, has a burning sensation

    HPI states: One day

    Can what is documented above in the CC be counted towards the HPI?

    Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Default Chief Complaint and HPI
    Yes, in the example you provided, you can count content in the "CC:" section as HPI. The E/M documentation guidelines state that required elements may be counted no matter where they are located in a note (e.g. ROS elements may be found in the HPI section). As long as you stick with what is documented and do not "double-dip" or count the same item as more than one element, you will be fine.

    The Chief Complaint is the concise statement of why the patient is seeking care, the reason for the visit, and it is usually documented in the patient's words. The HPI is the patient's subjective description of the course of the illness/injury up until this point. In your example, I would count "UTI" as the CC, and I would count two elements for the HPI: "symptoms present for one day" (duration) and "burning sensation" (associated signs and symptoms). One could argue that "burning" could be counted as a "quality" element instead, but you still end up with a two-element HPI.

    One last thing... the general consensus (supported by the documentation guidelines) is that the HPI must be documented by the Physician (or NPP), rather than ancillary staff, in order to be counted. In some cases, the MA or nurse may complete the "CC" line on the note and the physician may fill out the "HPI" line. While this does not necessarily change my opinions on any of the above, it is always good to encourage the physician to document all of the HPI detail, rather than delegating this task. It may require the physician to repeat and/or summarize the input from other documentors.

    Hope this helps!

  3. #3
    Location
    Everett, WA
    Posts
    886
    Default
    Can location be inferred (urinary tract) for one of the components thus making it four?
    Suzanne E. Byrum, CPC

  4. #4
    Default HPI in Chief Complaint
    I would say yes, the UTI can be used toward location. HOWEVER, not in this case. Because the UTI is being used as the chief complaint. It's not going to matter in the end any way, because that only gives three elements.
    Tiffany Fischer, CPC, CEMC

  5. #5
    Location
    Overland Park, KS
    Posts
    1,166
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    My thanks to all!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. #6
    Default
    Depends on who documented the CC. If ancillary staff did it, then no you can't count it towards HPI. If the provider did you are fine in counting it.

    Laura, CPC, CPMA, CEMC

  7. #7
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Laura,

    I forgot that! So true! Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  8. #8
    Default Chief Complaint
    I am auditing a Family Practice physician and on several of the charts the chief complaint is: The patient is here to establish care. Then in the "History of Present Illness" the physician will comment on all the problems the patient is having. My question is: what do I do about the chief complaint?? Thanks, Nancy

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