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location vs signs and symptoms

  1. Default location vs signs and symptoms
    Medical Coding Books
    Hi everyone, I hope someone can clear this up for me. In the HPI when the physician is writting the patient had a headache for 3 days would you identify headache as location or signs and symptoms? Also for abdominal pain how would you identify this location or signs and symptoms?
    Last edited by frugalecook1216; 07-06-2011 at 08:46 AM.

  2. #2
    Columbia, MO
    it is both.. It is a pain which is the symptom in the head which is the location.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    So I can give them credit for both?

  4. #4
    Columbia, MO
    yes it is just a word that combines two things.. If it said instead.. Pain with pain in her forehead for 3 days you would have no problem with saying location , symptom, duration. So patient with headache x 3 days is no different.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Milwaukee WI
    Default Associated Signs
    If the chief complaint is headache, then NO you can't count head pain (i.e. headache) as an associated sign/symptom. But if the doctor said patient has also had blurry vision, then the blurry vision would an associate sign/symptom.

    If the chief complaint was something else (e.g. sore throat), then headache could be considered an associated sign/symptom AND location.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. Default
    Thanks to both of you,

  7. #7
    Hi -

    I disagree with the last commnet reg. if the chief complaint were something else, e.g., sore throat, you could count headache as sign/symptom AND location.

    In that scenario I would give location for the throat, since that's were the problem is. The headache as a sign/symptom is OK.

    All the elements are related to the chief complaint - not to each other.
    Karolina, CPC, CPMA, CEMC

  8. Default
    for a visit for a headache I would use the ache(pain) as the chief complaint and the head as the location and 3 days for the duration

  9. #9
    Kansas City, MO
    Ok...well auditing can be subjective, and some of the guidelines are you may get varying responses...and here's my two cents.

    You can have two locations within an HPI if the two problems are unrelated (sore throat and ankle injury).

    When it comes the term headache, I would not give credit to two spots in the HPI for this one word.

    "Ache in the head"...different story.
    Last edited by LindaEV; 07-14-2011 at 03:27 PM.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  10. Default
    Quote Originally Posted by LindaEV View Post
    Ok...well auditing can be subjective, and some of the guidelines are you may get varying responses...and here's my two cents.

    You can have two locations within an HPI if the two problems are unrelated (sore throat and ankle injury).

    When it comes the term headache, I would not give credit to two spots in the HPI for this one word.

    "Ache in the head"...different story.
    Careful with that "two locations" thing. I think there may be ONE Medicare carrier that allows us to count it that way. The rest will say that every one of the 8 HPI elements can only be counted once, regardless of how many times that HPI element can be counted in the HPI statement.

    As to the original question question (regarding how to count the a presenting problem of "headache x3 days"), I would only count location and duration for that statement. Some folks might try to stretch that and say that "ache" is a quality statement. Yes, "ache" or "achy" can be a quality statement in SOME clinical contexts. But not this one. What you know from this statement is that the pain is in the head (location) and that it's been going on for 3 days (duration). We don't know anything more than that from this statement. If you were looking for a quality statement related to a presenting problem of headache, you'd see something like "dull", "sharp", "feel like a band around my head", "feels like a knife", etc. In other words, it would be an adjective that describes the type of pain.

    The reason "headache" wouldn't be counted as an associated sign/symptom (instead of lcoation) is that there's nothing to say what the headache is related to. If the patient sustained a head injury in a fall and was now complaining of a headache, in THAT context, headache would be an associated sign/symptom. But if the patient is complaining of a headache and you don't have any other symptoms that one might associate with a headache (blurred vision, nausea, ringing in the ears, sensitivity to noise, etc), then all you've got is the location of the symptom.

    One thing we can't forget when we're auditing is that counting HPI elements isn't about sticking word phrases into boxes. We MUST look at what's written from the perspective of what the doctor is looking at in his/her assessment of the patient (ie, we must look at the information from a clinical perspective).

    Interestingly, in my 12+ experience in auditing, I've found that if we look at what the doctor wrote from a clinical perspective (rather than from a "just count the elements" perspective), much of the subjectivity in E/M auditing goes away. For example, the example given by Karolina (headache and sore throat) - did you know that having a headache is one of the 4 classic symptoms that is present in a patient who is positive for strep throat? Asking a patient who presents with a sore throat whether they also have a headache is a classic example of an associated sign/symptom question for a sore throat presentation.

    Karolina, I don't mean this to sound like I'm picking on you. I'm just trying to point out that when we count our E/M elements, we need to think like the doctors are thinking. Otherwise, we're going to end up counting things we shouldn't (or missing things we should count).


    Joan Gilhooly, CPC, PCS, CHCC
    Medical Business Resources, LLC

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