# Multiple Chief Complaints



## SUEV (May 28, 2011)

If a patient is being seen for multiple issues, can you combine elements of the HPI to get an extended HPI?  Here's what's documented:

Chief Complaint: 
1. Right sided pneumonia.
2. Left decreased hearing.
Dictated HPI
Subjective: The patient arrives here today for followup with medical problems. Since this last appointment she has been to the ER diagnosed with right sided pneumonia. She has now completed her course of Avelox x7 days. She has had no fever or chills. She continues to cough.

She complains of intermittent loss of hearing on the left side with past history of this and questioning what it might be. 

If I separate them, I only have have location, modifying factors & assoc. sign/symptoms for the pneumonia  and timing & location for the hearing loss.  Can I combine them?  Am I missing something I can use?  Thanks for any help!
Sue


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## FTessaBartels (May 31, 2011)

*Count each element individually*

You can count each element of HPI for each problem.  So, for example, you can count location *twice* because your HPI specifies right-sided pneumonia and also left-side hearing loss.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## SUEV (May 31, 2011)

It most definitely helps.  I wanted to make sure the note qualified as an extended HPI in other auditors' eyes so that I wouldn't have to downcode from a level 4.  Thanks for the advice!


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## LTibbetts (May 31, 2011)

FTessaBartels said:


> You can count each element of HPI for each problem.  So, for example, you can count location *twice* because your HPI specifies right-sided pneumonia and also left-side hearing loss.
> 
> Hope that helps.
> 
> F Tessa Bartels, CPC, CEMC



I didn't realize that you could count a specific element more than once (for example, two points for location or two for timing, etc). Is this possible with every element of the HPI? I thought that you could only count an element of the HPI once, and the other points would have to come from another, different element. I have not done it this way so I'm afraid that I have been missing out. Thanks for the info! I am always learning something new from you!


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## RebeccaWoodward* (May 31, 2011)

I, too, found this interesting; as I have never done this.  I have a new Medicare carrier (Palmetto GBA) and am told that they do not allow using a single HPI bullet twice.  I would check with your carrier


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## ollielooya (May 31, 2011)

Another useful bit of information to check into.  It just makes sense that you would be able to count multiple bullets if the physician is addressing separate additional problems, and would love to followup on this at the next Palmetto MCR EM webinar.  ---Suzanne


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## rthames052006 (May 31, 2011)

SUEV said:


> If a patient is being seen for multiple issues, can you combine elements of the HPI to get an extended HPI?  Here's what's documented:
> 
> Chief Complaint:
> 1. Right sided pneumonia.
> ...



Best practice would be to check with your carrier.  I can tell you if you are in J12 area ( Highmark Medicare Services) you cannot get credit for an extended HPI for the above scenario.


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## valleycoder (May 31, 2011)

i didnt know you could count an element more than once either but i would definitely check the carrier before doing that.  

i was able to get a full HPI out of the pneumonia case:  


Subjective: The patient arrives here today for followup with medical problems. Since this last appointment she has been to the ER diagnosed with right sided pneumonia. She has now completed her course of Avelox x7 days. She has had no fever or chills. She continues to cough

Since this last appt = Duration

right sided = location

avelox = mod factor

no fever/chills = assoc signs/symptoms


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## Mojo (May 31, 2011)

This article addresses the E/M gray areas:

◦Documentation counted toward elements of HPI must relate to the chief complaint (except associated signs and symptoms). If the patient presents with multiple complaints, the coder may choose which one to consider the “chief” complaint and other problems may be counted as associated signs and symptoms, elements of ROS, or past medical history. The problem chosen should be the one that provides the documenter with the most complete HPI. 
■Example: A patient presents with arm pain from an accident and also complaints of arm numbness off and on. This counts as location (arm), context (accident), and associated signs and symptoms (numbness) but not timing (off and on) (off and on refers to timing related to the numbness, not the arm pain). 
◦A completely unrelated condition or symptom may not be considered an associated sign or symptom but if the coder is not certain whether the condition may be related the clinician should be given credit for the documentation.


https://depts.washington.edu/uwpsite/ComplianceSite/compliancePolicies/codingGuidances/emGrayAreas.html


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## LTibbetts (Jun 1, 2011)

Hey Mojo!!
Thanks for the link. there's good info in there that I can share with our newer coders!


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## rthames052006 (Jun 8, 2011)

*Thanks much!*



Mojo said:


> This article addresses the E/M gray areas:
> 
> ◦Documentation counted toward elements of HPI must relate to the chief complaint (except associated signs and symptoms). If the patient presents with multiple complaints, the coder may choose which one to consider the “chief” complaint and other problems may be counted as associated signs and symptoms, elements of ROS, or past medical history. The problem chosen should be the one that provides the documenter with the most complete HPI.
> ■Example: A patient presents with arm pain from an accident and also complaints of arm numbness off and on. This counts as location (arm), context (accident), and associated signs and symptoms (numbness) but not timing (off and on) (off and on refers to timing related to the numbness, not the arm pain).
> ...



Definately some good points in this article...

I thank you as well


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