Page 1 of 2 12 LastLast
Results 1 to 10 of 14

HPI Component

  1. #1
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default HPI Component
    Medical Coding Books
    I'm wondering what other coders understanding is of the "associated signs & symptoms" under the HPI means.
    Is it "positive" associated signs & symptoms (eg: pt has strep, with a rash)
    or is "negative" associated signs & symptoms (eg: pt has strep, no rash)
    or is either/or - positive & negative?

    I was always taught it was "positive" associated signs & symptoms - what else is happening when it occurs - but recently a provider has come to me and said that she was taught that even if it was a negative - it still counts under associated signs & symptoms. I understand what she's trying to say, but having trouble changing my view on it! So now I'm questioning my own understanding of it... everything I have points to positive associated signs & symptoms...
    any other opinions on this?

    thanks!
    Donna, CPC, CPC-H

  2. #2
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    wow! I'm surprised there aren't any replies to this! Doesn't any other coder have an opinion on the associated signs & symptoms in the HPI? Aren't there any other E/M auditors out there? How do you pull that info for the HPI, from positive signs, negative signs, or both?
    I'd sure appreciate any comments from others who do E/M coding & auditing.
    Donna, CPC, CPC-H

  3. #3
    Location
    Morgantown
    Posts
    44
    Default
    Donna,

    I would have to agree with you. I have always been told it is signs and symptoms of what is going on with the patient now. But now you have me wondering as well.
    Kimberely K. Graham, CPC, CPC-H

  4. #4
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    LOL...yeah, sorry -- I sort of had a feeling that's why there wasn't any replies yet! Now everyone is kind of second guessing ourself!

    we'll see - in the end, I'll have to ask the provider to show me her documentation on using negative - and see where it comes from.

    ThANKS for responding!
    Donna, CPC, CPC-H

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Great post Donna! I'm looking at your example and thinking that I would use "no rash" in the ROS. I also have the understanding that the associated sign/symptom should be a "positive". Then again, if the provider stated "no associated signs or symptoms" would we count that in the HPI?
    Lisa

  6. Default
    Do you believe that the doctor is getting confused with the ROS. I also understand and I seem to thing that I am confident in my coding knowledge until a doctor say "something different" and I know that it is not right, then I spend several days making sure that I was correct. All of my doctors like me to prove everything in black and white. I really hate it.

    kit

  7. #7
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Quote Originally Posted by KWtitans View Post
    Do you believe that the doctor is getting confused with the ROS. I also understand and I seem to thing that I am confident in my coding knowledge until a doctor say "something different" and I know that it is not right, then I spend several days making sure that I was correct. All of my doctors like me to prove everything in black and white. I really hate it.

    kit
    I am with you on that kit!

  8. #8
    Location
    North Carolina
    Posts
    3,126
    Default
    Donna,

    Although not often, I have seen documentation where the physician documents that the patient has chest pain that was not exacerbated by activity and no other assoc signs/symptoms... racing right into the ROS. I imagine due to the nature of the complaint, they were trying to make a quick assesment to determine the urgency of an ekg, crash cart, etc. I did present this scenerio at one of the E/M-Auditing workshops and was told that I could give credit for that statment. I have to agree that I normally perceive negatives as ROS. I find that this particular field is really a "toss up" sometimes. At times, it's a matter of interpretation from one auditor to the next.

  9. #9
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    thanks everyone for your input! I appreciate it!

    Lisa - yes, the provider has left me a bit confused right now, but honestly - everything I've found so far has been positive signs or symptoms - not what else "isn't" happening. (I guess that's why I'm having such difficulty wrapping my mind around using "no other signs/symptoms as a check mark under HPI) LOL
    KWtitans - I thought that was the case too - that perhaps she meant under the ROS (which of course I agree with) and actually, that's where I marked it under. BUT, she wanted it brought up to the HPI to make it a Detailed HPI. Like you, I'm confident also, and I really don't mind learning new things, new ways. My providers want proof in black and white also, but where's her proof to me? She told me (rather loudly) that she was positive she is correct and that this was how she was taught.. I told her, I wasn't saying she was wrong, I'm just saying "this is the way I was taught" AND I have documentation to back it up...then I showed her all my "tools" I have and use when doing the audits and asked her to show me hers, but she doesn't have any, she just knows she's right. I've been searching the web since!
    rebeccawoodward - I agree, it's a toss up area - It never was before to me, but now it seems to be -


    Here's what I've found out so far fellow coders:
    1) per a consultant from MEDLEARN her answer to the question is: You can count them in HPI if you have enough ROS and don't need them.
    2) I have found one area on the web, not even sure who it's by, just some random person that says - No pain, No fever, No Itch= No HPI element (for some auditors) <-- it included "some auditors". I take that to mean, some use them some don't.
    3) All of the fellow coders I used to work with, the ones I work with now, the fellow coders from forum (so far) and my supervisor feel the same about thinking that HPI signs/symptoms were positive and the negatives usually fall under ROS. It sure seems to be the "norm".

    and here's what I know for certain:
    1) She can't back up her claim (yet) as well as I can back up mine.
    2) I'm not changing my way of auditing until I can see for myself and understand the process change, IF there is one, until I have something that I can hold out and say - "THIS" is why I do things this way,(when they come to audit "my" audits!) Then, I'll be willing to change my process.
    3) and I really don't deal well with "ifs" and "buts" OR "somes"

    this issue should play out interestingly - I'll let you know what the outcome is.
    thanks again everyone!
    Donna, CPC, CPC-H

  10. #10
    Location
    Hartford, CT
    Posts
    723
    Default
    Hi,
    I just came across this question and thought I'd add my two cents. I don't count negatives as associated signs & symptoms, I add them to the ROS. My rationale is, how can something that doesn't exist at the moment be associated with something that is there? The other thing I look at is, Could I use this as a diagnosis (you can code rash, cough, etc, but there is no code for "no rash"), I probably wouldn't use it but if I can code, then I would probably count it.

    I'm with Donna, I can back up my audit with what IS documented, how can the doctor make an association with something that's not there? I'd add it to the ROS.

    Doreen

Page 1 of 2 12 LastLast

Similar Threads

  1. Tech Component US
    By mcwhirter in forum OB/GYN
    Replies: 1
    Last Post: 02-25-2010, 12:13 PM
  2. Exam component
    By krssy70 in forum E/M
    Replies: 4
    Last Post: 11-10-2009, 01:38 PM
  3. Professional Component
    By saave853 in forum Modifiers
    Replies: 3
    Last Post: 09-30-2009, 01:22 PM
  4. proffesional component
    By hudsondna in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 05-05-2009, 07:57 AM
  5. TC or Professional Component
    By aromo12340 in forum Modifiers
    Replies: 1
    Last Post: 11-10-2008, 01:33 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.