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.