# An HPI Question



## dballard2004 (Jun 14, 2010)

A co-worker of mine who is also an auditor brought up a very interesting question that I would like others opinion on please.  If the provider documents the following:

CC: Ear pain

HPI: Ear pain for three days

In this above scenario, would you count ear pain as the location element of the HPI?  My co-worker attended an auditing class this past week where they said that unless the provider specifically states something to the effect of "left ear pain, " it does not count as location but as associted signs and symptoms.  

To me the above would be location because you are stating that the pain is in the ear, but I do see the other side as well because you are not stating exactly where the pain is without elaborating further.

Any thoughts?


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## sbicknell (Jun 14, 2010)

I was on a Cardio webinar about a month or so ago and this was also discussed. Specifically stated that with "chest pain" that "chest" is not location. Physician must specifiy substernal, left-sided etc

I always have audited with "pain" as the CC and "chest" as HPI location. 

When I informed the physicians of this change they just laughed (among other things). I could not find anything from CMS/Trailblazer to back this up. I give high respect to the Webinar speaker and the info she provides, just can't find anything in writing

But I sure don't know how the seminar/class came up with "it does not count as location but as associated signs and symptoms"  for Ear Pain. What is the Ear pain Associated to? If ear pain is going to be Assoc S&S then there has to be CC of a different problem. Such as CC of Sinus Pain, Assoc S&S of ear pain

What happens to 
Headache---head now has to be left temporal
foot pain---foot now has to be right foot
abd pain---abd now has to be ULQ
So basically they are saying that head/foot/abd are non-specific and no longer meet the HPI element of Location? 

So does anyone have anything in writing?


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## PURNIMA (Jun 14, 2010)

Hi,

Good Day!

I would still count this in location. Just take an example of abdominal pain. if in HPI stated as abdominal pain, we dont look for specifics of which quadrant or side. We go with PE for further site. 

So is the same with Ear pain too, we can count it in Location, it is sufficient and remember HPI is a SUBJECTIVE note, and we cannot expect too many specifications.

Hope this helps you....

Thank You,

Purnima S, CPC


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## LLovett (Jun 15, 2010)

*I would love to see something in writing as well*

I would count it as location. That is unreasonable in my opinion to say it is not a location. 

Pain for 3 days, no location. Ear pain for 3 days, location is very evident. 

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

Q 22. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).
A 22. Yes. According to the E/M 1995 and 1997 DG, "The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness 

Laura, CPC, CPMA, CEMC


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## Lisa Bledsoe (Jun 15, 2010)

I would aslo count "ear" as a location.


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## sbicknell (Jun 15, 2010)

I think there is agreement that ear pain, chest pain etc all show location. But the webinar I was one was direct from CMS. I don't know the source for the info given out in the class dballard attended.

But both sources were very clear and stated the same thing. That ear and chest were insufficient for location and HPI statement must be more specific. 

The issue is has anybody seen this in writing? Until I do I continue to audit ear and chest as the HPI location of the pain

Anybody have the pleasure to know how the RAC auditors are auditing?


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## Jagadish (Jun 15, 2010)

I back Laura. Also please review the following excerpt:

If the physician dictates, “the patient presents with a headache that he has had for two days”, can we count both the Chief Complaint and the HPI element of location using this one statement?

Per WPS Medicare Part B, “If the chief complaint is headache the location of the HPI would be the head. (The two are very similar.) The remainder of the HPI elements would clarify the concern of the headache. The Chief Complaint and the HPI support each other, however, the same element cannot be assigned to both (HPI and ROS).”

Source: http://www.wisconsinmedicalsociety.org/education/faq


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## sbicknell (Jun 15, 2010)

This isn't about picking sides on this issue. The information has been given out by 2 separate sources. 

The guidance being given, that ear pain, chest pain do not support HPI location, can significantly impact the E&M level

Anyone have a source to verify? RACs, CMS, MCare FI?


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## dballard2004 (Jun 15, 2010)

According to my co-worker, the instructor states that, for example, knee pain would not be location because the provider is not specifying the exact location on the knee.  The rationale is that knee is a body part, not location.

Well....isn't a body part location?


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## jdibble (Jun 15, 2010)

OK - the way I see it is that, yes body parts are the locations.  I attended an In-Hospital E/M Seminar through our MAC, Highmark and they taught us that chest pain would be a location.  They also allow the information from the CC, HPI and ROS to be used without "double dipping."  In one of the examples that they used to go through with us for correct levels for a subsequent visit was:

"Feels comfortable, no complaints of chest pain.

On the score card we were told that Chest was Location under HPI and feels comfortable was Constitutional and chest pain was Cardio under ROS - giving us an Exapanded Problem Focused Interval History.

So, in my opinion and according to Highmark Medicare, chest, leg, abdomen, etc. are locations.

Jodi Dibble, CPC


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## Lisa Bledsoe (Jun 15, 2010)

dballard2004 said:


> According to my co-worker, the instructor states that, for example, knee pain would not be location because the provider is not specifying the exact location on the knee.  The rationale is that knee is a body part, not location.
> 
> Well....isn't a body part location?



Dawson - any possibility that the instructor could share his/her source?  I have always counted "ear" or "knee" or "eye", etc as the location...yes a body part is a location!    We are talking HPI here, right?  So how do we know the *exact location *of the knee/ear/eye/finger/breast/toe... until after the exam?


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## LindaEV (Jun 15, 2010)

Lisa Curtis said:


> Dawson - any possibility that the instructor could share his/her source?  I have always counted "ear" or "knee" or "eye", etc as the location...yes a body part is a location!    We are talking HPI here, right?  So how do we know the *exact location *of the knee/ear/eye/finger/breast/toe... until after the exam?



Agree. I would definitely count it as location, and will continue to do so until I get something in writing that says I can't. If my docs can demand everything in writing, so can I!


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## Lisa Bledsoe (Jun 15, 2010)

LINDALOUV said:


> Agree. I would definitely count it as location, and will continue to do so until I get something in writing that says I can't. If my docs can demand everything in writing, so can I!



Linda - I love that!!


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## dballard2004 (Jun 17, 2010)

I am total agreement with Linda!

From my understanding, the instructor tied this back to the E/M guidelines.  I researched the E/M guidelines and I find no directive on this there.  All I find is that "location" is one of the HPI elements.  I will ask for the source and post back here when I have an answer.

Thanks to all for the replies.


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