# HPI Component



## dmaec (Aug 4, 2008)

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!


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## dmaec (Aug 5, 2008)

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.


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## grahamki (Aug 5, 2008)

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.


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## dmaec (Aug 5, 2008)

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!


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## Lisa Bledsoe (Aug 5, 2008)

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


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## KWtitans (Aug 5, 2008)

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


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## Lisa Bledsoe (Aug 5, 2008)

KWtitans said:


> 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!


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## RebeccaWoodward* (Aug 5, 2008)

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.


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## dmaec (Aug 6, 2008)

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!


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## dclark7 (Aug 7, 2008)

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


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## dmaec (Aug 7, 2008)

Doreen,
exactly! how can there be an "associated NON sign or symptom"?  If there isn't a sign or symptom, how is it associated then? At least that's the way I see the negatives.  And yes, I'd count them under ROS.
Fortunately I'll be going to another work shop on E/M coding at the end of August   I have my questions ready for the speaker!

it's good to know I wasn't so "off base" in my line of thinking...great to know other coders tend to count components the same way.


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## RebeccaWoodward* (Aug 7, 2008)

Hey Donna...

Will you be sure to post what you find out?  I'm going to a Medicare E/M workshop in two weeks.  Hopefully, I don't get escorted to the door before I have all my questions answered.  (Hee Hee)


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## dmaec (Aug 7, 2008)

this just in from a Senior Consultant: From the consultant that will be giving the E/M auditing presentation I'll be going to on August 28th! 
"HPI associated signs and symptoms can be positive OR negative; provider gets credit for asking, even if patient says there are none.
Hope that helps, 
Nancy
Partners Healthcare Consulting, A Service of WIPFLi LLP"


well, it didn't help   it made matters worse! LOL.. I'll be talking to her in August face to face about this.  I've been looking everywhere for hard copy information on being able to do this (negatives counted in HPI) but haven't found anything.  Only, opinions.  I've looked at a few E/M's that I've recently completed, and honestly - if I start throwing negatives in the HPI I can get a level 4 E/M almost every time! I don't think outside auditors are going to like that!

Rebecca - I'll let you know what she says after August 28th.  and would you please ask the same question at the Medicare workshop, I'd be interested to know their take on it too!
thanks!!


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## RebeccaWoodward* (Aug 19, 2008)

Donna,

As I promised...I wanted to report what Medicare stated in front of an entire audience

Q:Can the provider receive credit for positive and negative HPI?  Example: Provider documents...Chest pain-no other associated signs and symptoms 

Medicare's representative response-

A: A Provider can receive credit for documenting positive and negative responses for HPI.

Comments?


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