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What's your opinion?

  1. #1
    Default What's your opinion?
    Medical Coding Books
    When you are auditing an E/M visit and you are looking at the details of the HPI - can location be assumed? If the dx is "heartburn," doesn't that infer the location? Or would the physician need to specify where the heartburn is located.

    I realize that you need 4 or more details to reach a level 4 or comprehensive HPI. And, as you know, the details of the HPI are:

    location, quality, severity, timing, duration, context, modifing factors, associated signs and symptoms.

    Let's say I have an HPI that has documentation of duration (present since 2/08) modifying factors (taking Tums) and context (symptoms disappeared while on vacation and free of stress). Can I give credit for documenting the location, since Heartburn can only be located in one area?
    Last edited by Colliemom; 09-04-2008 at 12:01 PM.

  2. #2
    North Carolina
    I like your question. By definition, heartburn is a burning sensation in the substernal area due to reflux of acid contents of the stomach. Personally, I would give credit since it is inferred. I'm sure your question will be a topic of interest for others.
    Last edited by RebeccaWoodward*; 09-04-2008 at 11:17 AM.
    Rebecca CPC, CPMA, CEMC

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  3. #3
    Default Similiar Question....
    I would give credit too.

    I actually have a similiar question....

    "blood sugars in high 200's..." would you consider "blood" location? - that sounds like a silly question. but the DM pts I feel are difficult to apply the HPI elements if they have no other chronic issues...

    I always get HPI's that say ....."blood sugars controlled or uncontrolled, what meds the pt is on, and how long they've had dm." So for history, I'm always getting problem focused or expanded problem focused

    These pts often take up very much time of the physicians and they feel like they should be able to "code higher" but aren't sure what exactly or how the HPI elements could be applied to diabetics b/c of no somatic complaints. I know they can always code based on time but I'm specifically speaking to the key components. It's often always the "history" that brings down the level of e/m.

    Any insight?
    Last edited by ARCPC9491; 09-04-2008 at 11:22 AM.

  4. #4
    Dover Seacoast New Hampshire
    AR, for "blood sugars in the.....", I'd consider associated signs and symptoms. The fact that "blood" is mentioned has nothing to do with the condition which falls under the endocrine system. Personally, I wouldn't consider it location.

    Your HPI needs one more element....modifying factors is easy if they discuss medication/diet/exercise as related to the control of DM. If you can get them to mention that, you'd be able to get a detailed HPI. Pam

  5. #5
    Just a thought, but could your docs use time as a determining factor when they spend a good deal of time with those diabetic patients? They would have to document the total time spent and time spent counseling and a brief statement of what was discussed but that may help more than trying to expand the HPI or other history element. Also, an established patient requires only tow of the three key elements, and Medicare says one of those is MDM, so maybe HPI would not have to be comprehensive every time. Just rambling thoughts...Lynn Kimsey, CPC, CPC-I, CPC-E/M

  6. #6
    I don't think I would use location but maybe Quality? If the CC is "pt her for DM ck" then their BS wouldn't be associated sign or symptom....maybe nausea or headache for this area.
    adrianne, cpc

  7. #7
    Thanks Rebecca, I appreciate your help, as always!

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