Alphabet Soup: Acronyms and E&M Coding

As healthcare professionals, we have a lot of acronyms to keep straight, don’t we? Feels like alphabet soup in my head some days. I’m reminded of a scene in the movie, Good Morning Vietnam, where Robin Williams’ character has an entire conversation using acronyms, making fun of the military jargon. We could do the same in healthcare, especially in E&M coding.

Today, let’s think a bit about HPI, not to be confused with PHI. If you have a translator in your head the way I do, these two don’t even sound the same, but for those outside the realm of coding, these acronyms can get confusing. PHI is Protected Health Information. HPI, or History of Present Illness, is the portion of the E&M (Evaluation and Management) visit during which the patient describes why they are seeing the physician. When I provide education on E&M documentation and scoring, I talk about this section being the one containing the adjectives. This is the how, what, why, when, and where of the patient’s problem. However, in the Documentation guidelines the titles are Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Signs and Symptoms.

So, let’s say a sick patient goes to her doctor complaining of a cold she can’t shake. Usually the medical assistant gathers the HPI. The patient, now speaking from behind a mask because she’s actually sick at a doctor’s visit, describes the cold. “I started getting a sore throat after attending a healthcare convention in Las Vegas, AHIMA to be specific. That was two weeks ago. No fever, no nausea or vomiting, but I do have aches, pains, and ongoing congestion. I’m using OTC medication to treat the symptoms.” Kind of reads like the patient has audited a few E&M notes, doesn’t it?

Without looking at me… er, I mean the patient, the medical assistant enters information into her computer and continues asking questions: “Any change in appetite? Any shortness of breath? Trouble sleeping?” These questions are prompts targeted to elicit additional information about the state of the patient. These questions relate to the ROS, or Review of Systems.

So, what happens if the patient answers ‘yes’ to any of these questions? These questions do relate to the condition being examined, but they aren’t really the patient’s narrative of the condition, or Chief Complaint (CC). What started out as HPI of the E&M now includes ROS and CC. Alphabet soup.

But, back to the task at hand. In order to score this visit, the coder needs to categorize the elements of the provider’s record of the visit. With the information provided by the patient, we have a number of elements to count. We have location (throat), duration (two weeks), modifying factors (OTC drugs) and associated signs and symptoms (aches, pains, congestion). What about some of the other information? Does documentation of a negative count? The patient stated “no fever, nausea or vomiting.” Because the E&M document is a record of the provider’s analysis of the patient’s chief complaint, negative statements are part of that analysis. The lack of fever is important diagnostic information. The patient doesn’t have an infection.   So, I would certainly count that information in the Associated Signs and Symptoms section. Additionally, the documentation guidelines state that the CC can be implied. So, we have a CC of “Cold” and four HPI elements.

Now, let’s go back to those questions that made up the ROS. If the patient stated that she does indeed have shortness of breath, is that an associated sign/symptom? Well, maybe. Because the documentation guidelines require four HPI elements to support the higher levels of care, a coder may elect to count this as an HPI element if she/he only has three without it. However, if there were no other ROS elements documented, the coder may elect to count that statement as a review of the Respiratory system. A third option is available, however, but it is one that can cause some coders to do battle with each other. That option is to count the statement as both HPI and ROS.

Years ago, in fact in 1998, Dr. Bart McCann, Executive Medical Director for HCFA (now CMS), wrote a letter addressing this issue. In the letter, he confirmed that an item of history did not need to be restated in order to be counted as both HPI and ROS. Some coders would call this double-dipping, which is a misunderstanding of the issue. Double-dipping, at the time the term was coined, was in direct relation to a statement being counted for two elements of the HPI.   For example, if the patient states “my headache gets worse at night,” the coder can’t count this statement as both Timing and Context. However, this misunderstanding has now persisted to the point that several MACs have made a determination one way or the other as have many clinics’ compliance departments. Some allow counting the system(s) addressed in the HPI to count as systems review, others don’t.

So, regardless of the final level of care (I’m feeling much better by the way), many factors impact how a coder scores a note. With two sets of documentation guidelines and multiple ways those guidelines can be interpreted, plus external direction from experts and MACs, is there any wonder the OIG recently published a report that Medicare had paid “billions of dollars in improper payments each year” for E&M services? HPI is just one third of the history section which is just one third of the document used to support the provider’s billing for the service.

For E&M coding, evaluating the HPI, capturing the CC, and tweezing out the ROS can be challenging; we haven’t even ventured into PFSH, or MDM. You know, I think some soup would taste pretty good right now. Alphabet soup.

Link to CMS document guidelines.

Rebecca Caux-Harry, CPC, is the CodeRyte Product Specialist for Cardiology with 3M Health Information Systems.

6 responses to “Alphabet Soup: Acronyms and E&M Coding

  1. The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. The HPI is documented by the provider.

    • Rebecca Caux-Harry

      Yikes! Thanks for catching my error. I will update my blog with the correct information. My apologies and sincere thanks for catching that.

  2. Excellent review of the ROS in HPI issue. Dr. Bart McCann’s letter is actually a very good read. The ACEP had that letter on their website, although I can no longer find it there. I did find this, which reportedly paraphrases it:

    So when do you start counting HPI elements as ROS? After you reach the four HPI elements? Never unless its under its own ROS header? Where is the line drawn? Does the provider needs to say the patient is short of breath in both the HPI and the ROS to have it count for respiratory? I think its easy to see how providers get frustrated with how their work is tallied, especially if they are required to repeat themselves in a note for a reason that doesn’t improve care or improve the clarity of content in the note itself.

    Interestingly, I’ve also worked with coders who insisted the count to 4 in HPI was per symptom, so if you got to 3 with shortness of breath, you’d need to start counting over with the next symptom of fever. I’ll clarify that it was another coder and not an auditor, although if this happens in the coding world it certainly could be happening in the auditing world.

    Glad you are feeling better.

    • Rebecca Caux-Harry

      Kathy, thanks for the comments. Regarding counting systems of the HPI as ROS, I count them all because the MAC under which I code has not limited my ability to do so. So, as the provider documents a symptom of a particular system, like shortness of breath, I would count this as an Associated Sign or Symptom and a Respiratory System review, regardless of how many HPI elements or systems reviewed. Some MACs prohibit this, as do some internal compliance programs.

      As to the issue of 4 HPI elements per complaint, I’ve heard this discussed by some coders, but this direction isn’t in any official documentation guidelines. Some coders are educated internally, without benefit of reading those guidelines. While they think they are coding compliantly, they are actually creating unnecessary blockage to appropriate reimbursement for their providers. When in doubt, I always go back to the official guidelines.

      • Oh I don’t disagree on the 4 HPI per complaint, but even when it isn’t in the guidelines, you do have coders out there doing it that way, either learned by coding internally or heard it at a seminar (its amazing what comes out of seminars that isn’t in the guidelines). I’ve been coding since, well can I just say prior to the guidelines being implemented, so I’ve seen a lot (I hesitate to say seen it all, because every time you say that, you’ll run across something else!). Its the inconsistencies in the way this is counted that drives the physicians crazy, and who can blame them?

  3. Rebecca Caux-Harry

    Thanks for the comments. I think it’s important to distinguish between CMS documentation guidelines, CPT coding guidelines, MAC scoring guidelines and lastly, internal guidelines. It’s a wonder that two coders ever agree with each other on the specifics of scoring a note. I believe this is why internal guidelines are so important. Those internal guidelines take into account all of the differing scoring methods out there and establish consistency internally. The problem comes when coders, educated internally, don’t know the difference. We all need to help each other achieve our best. I love these types of discussion because I always get to learn.

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