# calculating the HPI level



## Colliemom (Feb 13, 2018)

Need your help...if you were auditing the following HPI, what elements would you assign?  This is a new patient visit, referred for possible colonic resection after discovery of a mass found during a screening colonoscopy.

Prior screening: colonoscopy.  Denies risk factors.  There are no associated symptoms.  Pertinent negatives include abdominal pain, change in bowel habits, change in stool caliber, constipation, decreased appetite, diarrhea, melena, nausea, rectal bleeding, vomiting, weight gain or loss.  No family history of colon cancer, Crohn's or colitis.  No NSAID use.  Colonoscopy on 1/31/18 mass found in rectosigmoid.


thanks in advance!


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## ellzeycoding (Feb 13, 2018)

I don't code for GI, but just my thoughts.

Location: Colon/rectosigmoid
Duration: since 1/31/2018?


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## twizzle (Feb 14, 2018)

*Calculating the HPI level*



ellzeycoding said:


> I don't code for GI, but just my thoughts.
> 
> Location: Colon/rectosigmoid
> Duration: since 1/31/2018?



....and context; found on colonoscopy.


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## ellzeycoding (Feb 14, 2018)

twizzle said:


> ....and context; found on colonoscopy.




Mmm... not sure I'd buy that as Context.

Context = what causes it to occur.   The colonoscopy didn't cause it.

From AHIMA...

Context — Surrounding events or where the patient is, and/or what the patient does when the symptom or problem begins. Examples include "fell going up stairs," "left tibia fractured while playing soccer," or "only happens when I eat green peppers." Situational stress such as "anxiety only when my ex-husband is around" qualifies for context.


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## twizzle (Feb 15, 2018)

*HPI element 'context'*



ellzeycoding said:


> Mmm... not sure I'd buy that as Context.
> 
> Context = what causes it to occur.   The colonoscopy didn't cause it.
> 
> ...



I have to disagree with you. Context can also apply to a situation when the problem was first discovered, either by the patient or by someone who is managing the patient, even in the absence of symptoms....routine EKG for example, screening colonoscopy for example. In other words, context does not have to be when a problem started, but when it was first detected.


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## ellzeycoding (Feb 15, 2018)

twizzle said:


> I have to disagree with you. Context can also apply to a situation when the problem was first discovered, either by the patient or by someone who is managing the patient, even in the absence of symptoms....routine EKG for example, screening colonoscopy for example. In other words, context does not have to be when a problem started, but when it was first detected.




Interesting.  Do you have a source or citation to back this up?    

By this logic, 1 HPI factor automatically for any patient that presents for a problem and the doctor or patient detects the issue. To me this sounds more like 'duration' vs 'context'


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## twizzle (Feb 15, 2018)

ellzeycoding said:


> Interesting.  Do you have a source or citation to back this up?
> 
> By this logic, 1 HPI factor automatically for any patient that presents for a problem and the doctor or patient detects the issue. To me this sounds more like 'duration' vs 'context'



Good morning.

There are several references that back this up but this one is from the Health Care Compliance Association.
https://www.hcca-info.org/Portals/0/PDFs/Resources/library/Audit Manual.pdf (specifically page 4). Excerpts are taken from CPT assistant. 

An example given is 'found on chest x-ray'.

Hope this helps.


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## Colliemom (Feb 15, 2018)

thanks everyone, this is very helpful,

I was thinking 
location for mass in rectosigmoid and possibly context.  I guess duration might be appropriate too, but I just don't see a fourth element.  Also, would you all agree that "pertinent negatives" would never be counted toward the HPI elements?


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## stephanie.moore@wdhospital.com (Feb 15, 2018)

Per CPT Assistant, April 1996 

Context

To understand the context, a physician may obtain a description of *where the patient is and what the patient does when the symptoms or signs begin*. Is the patient at rest or involved in an activity? Is the symptom aggravated or relieved, or does it recur with a specific activity? Has situational stress or some other factor been present preceding or accompanying it? 


I can appreciate why you would accept the finding as context based on the guidance that you have received from HCCA. I would be cautious because I am not sure that if a CMS reviewer came in they would accept that information as acceptable regulatory guidance where as CPT Assist and AHIMA are. 

In regards to the original question I get the following HPI elements:

Duration
Location 
Signs/Symptoms

NGS states in the FAQ's the following:

Do Medicare auditors count negative responses towards elements in the HPI? 

Answer: Both positive and negative responses on HPI questions are counted. Updated 6/9/2017

https://www.ngsmedicare.com/ngs/por...tCbVS08vfgGhMseZ/dl5/d5/L2dBISEvZ0FBIS9nQSEh/

I hope you find this helpful.


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## ellzeycoding (Feb 15, 2018)

twizzle said:


> Good morning.
> 
> There are several references that back this up but this one is from the Health Care Compliance Association.
> https://www.hcca-info.org/Portals/0/PDFs/Resources/library/Audit Manual.pdf (specifically page 4). Excerpts are taken from CPT assistant.
> ...




Thanks, but I went further and I actually pulled the 1996 CPT assistant referenced in the PDF you linked.

Unfortunately, the example "found on chest x-ray" was *not *part of the CPT Assistant article or Vignettes.  In fact none of the italicized text in that section of the PDF document above are in the CPT Assistant.  Some of the text appears to be examples created by HCCA, to explain the excepts from the CPT Assistant, but not actual examples generated by the AMA.

I'll keep looking.  I'd like to have a more definitive, authoritative example, of time or point of detection = context. I want to believe.

For me the authoritative sources, defend-able in an audit are CPT and CMS E/M Guidelines.

Perhaps it's because I work and consult in the dermatology world, and a dermatologist examine and discover skin lesions, many of which the patient are unaware of.  If they examine and discover a melanoma on the patient's back as part of an annual skin exam, they'd never consider that discovery "context" as part of the HPI.


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## stephanie.moore@wdhospital.com (Feb 15, 2018)

Karl,

I believe you misunderstood me. I agree with you. I don't feel that context should be counted. I was including that CPT assist to support my rationale maybe I wasn't clear.


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## ellzeycoding (Feb 15, 2018)

Stephanie, we replied at the same time. I am on board with you. I was rebutting (at the same time as you), the previous poster's comment.  You hit reply first, so yours appeared while I was still typing.

We basically said/agree the same thing points.


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## stephanie.moore@wdhospital.com (Feb 15, 2018)

Excellent !! My mistake.

Have a great day!
Steph


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## twizzle (Feb 15, 2018)

*HPI elements*



stephanie.moore@wdhospital.com said:


> Excellent !! My mistake.
> 
> Have a great day!
> Steph



According to MCR's MLN, context includes 'how it happened' Well, we don't know how the mass happened but we do know that it happened to be diagnosed at colonoscopy.

You may also want to take a look at Deb Grider's Medical Record Auditor (AMA publication) to see her take on context.

At the end of the day, where would you place 'discovered during an EKG or colonoscopy' in the HPI elements? It's certainly not timing but it is the manner in which the event occurred.

To be continued.


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## ellzeycoding (Feb 15, 2018)

CMS states...

2. The documentation of each patient encounter should include:

reason for encounter and relevant history, physical examination findings, *and prior diagnostic test results;*
assessment, clinical impression, or diagnosis;
plan for care; and
date and legible identity of the observer.


Not everything documented is countable towards HPI.  There are some things documented that just don't fit, so you don't get credit.  Sometimes you can make things fit.  I can't find anything that says that your example is equivalent to _context._

But it's an interesting discussion.  Perhaps others will chime in.


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## twizzle (Feb 16, 2018)

*HPI elements*



ellzeycoding said:


> CMS states...
> 
> 2. The documentation of each patient encounter should include:
> 
> ...



It is an interesting discussion and I am surprised there hasn't been other's perspectives.
It does show how ridiculous E/M has become, because we are basically micro-analyzing one word which can determine how many $'s a provider gets. 
It should come down to 'what does the word mean?'

Anyway, we may or may not pursue this further.

Have a great Friday.


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