# can gradual onset be counted in HPI? Need help ASAP thanks



## Networker3412 (Mar 14, 2011)

Need help calculating HPI: 

cc-sore throat

onset/duration-2 days 

gradual onset 

no context and several assoc symptoms

Is there are only 3 HPI : durantion , associ symptoms and location or is there 4 with the gradual onset? 

Is gradual onset counted as timing in the HPI level or is this part of duration???


----------



## eadun2000 (Mar 14, 2011)

littlebit29 said:


> Need help calculating HPI:
> 
> cc-sore throat
> 
> ...



Gradual onset can be counted under timing.  Hope this helps.


----------



## Networker3412 (Mar 14, 2011)

we have having a difference of opinion to this situation. So since there are 4 elements in HP, we have 4 in the ROS that was documented, completed personal hx, fam hx and the exam was detailed exam. THe final dx was tonsilitis. Pencillin was give. One coder says that we should not be coding this as a level 4 before and i think it is a level 4. They say that its based on medical necessity and that tonsilitis is not that severe of a diagnosis to code a level for. This is in the ER so we are looking on 99284 vs 99283. Dont we have to code by what the physician documents and not based on our personal opinion??? They are telling me that the risk is low so you cant code a level 99284 even though the documentation supports the level 4. Please help thanks


----------



## eadun2000 (Mar 14, 2011)

littlebit29 said:


> we have having a difference of opinion to this situation. So since there are 4 elements in HP, we have 4 in the ROS that was documented, completed personal hx, fam hx and the exam was detailed exam. THe final dx was tonsilitis. Pencillin was give. One coder says that we should not be coding this as a level 4 before and i think it is a level 4. They say that its based on medical necessity and that tonsilitis is not that severe of a diagnosis to code a level for. This is in the ER so we are looking on 99284 vs 99283. Dont we have to code by what the physician documents and not based on our personal opinion??? They are telling me that the risk is low so you cant code a level 99284 even though the documentation supports the level 4. Please help thanks[/QUOTE
> 
> Was the Penicillin given IM or IV?  Also, how many bullets on the exam do you have?  Does the patient have any pre-existing conditions?


----------



## Networker3412 (Mar 14, 2011)

The pencillin was given as a script and there was a detailed exam with 7 organ systems. I am also reading the article on MDM for the risk in and i dont understand. I am still coming up with a level 4 and others are coming up with a level 3??? any help would be appreciated.


----------



## eadun2000 (Mar 14, 2011)

you could justify a level 4 if the patient had any IV or IM meds or if labs were done.  However, without any of those, all you have is a level 3.  A prescription was given.  You have nothing to defend a level 4.


----------



## Networker3412 (Mar 14, 2011)

Im sorry a lab was done to check for strep throat. the other coders are worried about coding this as a level 4 because they were taught that level 4 have to be more serious than tonsilitis..... from everything that i have reviewed documentation wise on this patient i came up with detailed hx, detailed exm and a moderate mdm which codes to a 4. they want to downcode this to a level 3 just because of the diagnosis given????


----------



## eadun2000 (Mar 14, 2011)

littlebit29 said:


> Im sorry a lab was done to check for strep throat. the other coders are worried about coding this as a level 4 because they were taught that level 4 have to be more serious than tonsilitis..... from everything that i have reviewed documentation wise on this patient i came up with detailed hx, detailed exm and a moderate mdm which codes to a 4. they want to downcode this to a level 3 just because of the diagnosis given????



Okay, all they did was a rapid strep.. that does not constitute the labs that I was thinking... like a CBC, etc; something with a venipuncture.  You are not downcoding this chart at all with the level 3.  Severity of the diagnosis/disease plays a part in MDM.  You cannot code an ER chart by only what was documented.  Risk and MDM have to play a part in it.  All the doc did was do a rapid strep and send them home with a script.  The highest you can code is a level 3.  Even if the physician had documented a full HPI, full ROS, full history and 8+ systems does not mean that the code is automatically a 4 or a 5.  When you have full documentation, you have to look at risk and MDM.  What did the physician do?  What were the risks?  If they ordered a CT of the neck and gave the patient some dilaudid or fentynl and ordered labs, then you could possibly code a 99285.  However, in this instance all that was done was the swab and the script.  It does not warrant a 99284 and to code as such would be upcoding.  If you would PM me your email address, I will send you a tool tonight to help with determining levels in the ER.


----------



## Networker3412 (Mar 14, 2011)

Thank you for clarify this. This helps alot. on our t-system sheet that the hospital told us to use they put in the lab section any test that needs to be taken to the lab etc. I will forward this on to my coworkers.


----------

