# HPI Elements - please settle a dispute



## MnTwins29 (Jul 9, 2012)

One of our physicians is disputing my findings on one of her records because of an HPI element.   This would make the difference between 3 or 4 elements to give an increase in the level of history.

On the HPI for knee pain, it is documented that the pain is "constant, worse at night."  I say this statement can be used for timing.   The physician says that she can use it for timing (constant) and for modifying factors (worse at night).   I maintain that statement can't be a modifying factor because the patient can't control that - night time is going to come, no matter what the patient does!

Thoughts?


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## cfellowscpc (Jul 9, 2012)

Lance, you are correct. If the patient said it was worse at night _when I lie down_ then the statement could be used as a modifying factor. Otherwise, there is no influence (action) that impacts the symptoms, the time of day (or night) cannot be considered something the patient did to alter his symptoms.  Good Luck!


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## btadlock1 (Jul 9, 2012)

MnTwins29 said:


> One of our physicians is disputing my findings on one of her records because of an HPI element.   This would make the difference between 3 or 4 elements to give an increase in the level of history.
> 
> On the HPI for knee pain, it is documented that the pain is "constant, worse at night."  I say this statement can be used for timing.   The physician says that she can use it for timing (constant) and for modifying factors (worse at night).   I maintain that statement can't be a modifying factor because the patient can't control that - night time is going to come, no matter what the patient does!
> 
> Thoughts?



The whole statement is Timing. Modifying factors are actions that the patient takes, that somehow affect their problem - either by making it better (or at least, attempting to), or making it worse. Examples would be "Not improving with OTC meds", or "Using a heating pad has helped", or "Pain is worse when patient is standing for long periods of time".

Timing, on the other hand, describes the frequency and/or specific time of day, in which a symptom occurs. I may be wrong, but I believe that the description "worse at night" is one of the textbook examples, given for that element. You sir, are correct in your scoring.


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## btadlock1 (Jul 9, 2012)

Ha! I was right...see page 12: http://campus.ahima.org/audio/2009/RB111009.pdf


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## MnTwins29 (Jul 10, 2012)

*Memories....*

I got a chuckle out of that, Brandi - because go to the slide with the names of the "faculty" - who is presenting the audio conference!   My, my, the "old-timers disease" is getting worse as the years go by....


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## btadlock1 (Jul 10, 2012)

MnTwins29 said:


> I got a chuckle out of that, Brandi - because go to the slide with the names of the "faculty" - who is presenting the audio conference!   My, my, the "old-timers disease" is getting worse as the years go by....



Ha! What are the odds? I totally didn't see that...


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## ollielooya (Jul 10, 2012)

Hey, you two aren't the only ones enjoying the chuckle here.  It's a good way to start the day knowing that I'm not the only one affected by "old-timer's!  Very funny indeed...


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## ksd (Jul 10, 2012)

I can see where the dr is getting modifying factor by worse at night.  Wether you can control nigh time coming or not, night time brings on higher dew points and often humidity which effects a lot of conditions such as arthritis.  So, by saying it is worse at night you could be saying it is worse when the dew point is higher for one example.  This will come down to the coder feeling comfortable arguing it as a point for HPI.


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## btadlock1 (Jul 10, 2012)

ksd said:


> I can see where the dr is getting modifying factor by worse at night.  Wether you can control nigh time coming or not, night time brings on higher dew points and often humidity which effects a lot of conditions such as arthritis.  So, by saying it is worse at night you could be saying it is worse when the dew point is higher for one example.  This will come down to the coder feeling comfortable arguing it as a point for HPI.



"worse when the dew point is higher " isn't a modifying factor - that's context.

There's a fine line between Context and Timing, and sometimes it's difficult to tell them apart. I define Context as pertaining to a specific circumstance or event, that is believed to have influenced the problem, but I categorize 'time of day' information, as Timing.

The dew point level is an environmental factor that fluctuates, and could potentially aggravate a problem, so it's Context. Other examples of phrases that are Context:
Pain is worse while lying down
Feels nauseous after eating
Difficulty breathing following exertion

"Worse at night", would only be considered Context, if something specific about nighttime, could be identified as influencing the problem (the only example I can think of offhand, is a vision problem, like night-blindness);

Aside from our sense of sight, our bodies have little to go on, to differentiate between 'Night" and "day" - those terms are used to describe a time of day, relevant to the patient's personal history. A person may experience a problem that's worse at night, but the clinical relevance of knowing that, may vary, depending on whether they have a normal schedule, or if they work overnights, and sleep during the day. 

With only a few exceptions, "at night", "in the morning", "during the afternoon", and similar statements, are primarily a point of reference, that demonstrates the frequency, in which symptoms occur - Timing.


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## FTessaBartels (Jul 10, 2012)

*Modifiying Factors*

Modifying factors refers to action/ treatments taken by the patient (or other care providers) and how that has affected the condition.

Using a heating pad
Taking OTC
Previous knee surgery

I would count "Constant, worse at night" as timing.  A statement such as: "Worse after standing for several hours," or "Noticed after basketball practice" - would be considered as context.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## melzinser (Jul 11, 2012)

*HPI elements per CPT Assistant*

"constant" = *quality*
"worse at night" = *timing*

I refer you to the descriptions of HPI elements in the April 1996 CPT Assistant.  Here is an excerpt:

_Quality

The physician should encourage the patient to describe the quality of the symptom, since some diseases or conditions produce specific patterns of complaints. For example, pain may be described as sharp, dull, throbbing, stabbing, *constant *or intermittent, acute or chronic, or stable, improving or worsening._


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## MnTwins29 (Jul 12, 2012)

*Oh, wow....*

thanks, Melanie - I think!   Thought we had it settled, but if the doctor sees this CPT Assistant, I am sure she will refer me to it as well.   Interesting to interpret "constant "as quality.  Although we never claimed E/M coding was an exact science.


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## sullivak (Jul 12, 2012)

*Elements*



TMORGAN said:


> Depending on what other two elements were counted from the remainder of the physician docmentation I can see this being two elements. I would use "constant" as quality and "worse at night" as timing.  Again, this is without knowing what elements have already been counted.
> Tiffany Morgan, CPC, CPCO, CPMA, CEMC



I agree with you, Tiffany and Melanie.  On the face of it, I would count "constant" as quality because it is describing the pain.  And I would count "worse at night" as timing, definitely not a modifying factor.


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## btadlock1 (Jul 12, 2012)

MnTwins29 said:


> thanks, Melanie - I think!   Thought we had it settled, but if the doctor sees this CPT Assistant, I am sure she will refer me to it as well.   Interesting to interpret "constant "as quality.  Although we never claimed E/M coding was an exact science.



I haven't seen the CPT Assistant, in question, but it's not the final authority on HPI elements, and I've found several other reputable sources that disagree:

http://www.doctors-management.com/images/ProductImage_653.pdf (Page 10)
"B. History of Present Illness HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are: Location. For example, pain in left leg; Quality. For example, aching, burning, radiating; Severity. For example, 10 on a scale of 1 to 10; Duration. For example, it started three days ago; *Timing. For example, it is constant or it comes and goes;* Context. For example, lifted large object at work; Modifying factors. For example, it is better when heat is applied; and Associated signs and symptoms. For example, numbness."

http://www.physiciansnews.com/2008/07/16/documenting-a-solid-hp-part-i/
*"Timing: These elements are documented by terms such as constant*, intermittent, occasional, unrelenting, coming in waves, etc."

https://www.cms.gov/Outreach-and-Ed.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf (page 10)
*". Timing (example: constant or comes and goes);"*

On a side note: I found some other interesting links that have good information on E/M services...they are a little off topic for this question, but I thought they were worth sharing...
http://www.aafp.org/fpm/2010/0700/p27.html ("Is Your Medicare Payer Playing by the Rules?: Don't let varying interpretations of the evaluation and management guidelines keep you from getting paid."

http://www.aafp.org/fpm/2010/0700/fpm20100700p27-rt1.pdf
("EVALUATION AND MANAGEMENT SERVICES Q&A:
HOW DOES YOUR MAC INTERPRET THE GUIDELINES?")


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## btadlock1 (Jul 12, 2012)

*A couple more...*

"Timing: the symptoms come and go, constant
ringing in the ears, it lasts for brief moments and
subsides"
http://aapcperfect.s3.amazonaws.com...fb18/14312958-cbc2-4248-aef4-86ef29d9e03e.pdf (Page 4)

"TIMING (it is constant, it comes and goes)"
http://www.palmettogba.com/Palmetto/Providers.Nsf/files/ACT_Evaluation_and_Management_Handout_020811.pdf/$File/ACT_Evaluation_and_Management_Handout_020811.pdf (Pg. 16)

"Timing: worse at night, daily, constant, frequent"
http://static.aapc.com/a3c7c3fe-6fa...fb18/170d31fa-a5c9-4966-85e9-38e2f6ce4b52.pdf (Pg 13)


Okay...I'm done!


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## MnTwins29 (Jul 12, 2012)

*Thanks for sticking to your (our) guns!*

Wow, Brandi, that is an impressive list of references.   I knew of the CMS example and that is what I used during my discussion with the doctor that lead to this question.    I certainly want to check out that article on how the MAC interprets the guidelines.


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## btadlock1 (Jul 12, 2012)

*One last note...*

I did see the CPT Assistant info (or, at least a larger excerpt of it, on this thread: https://www.aapc.com/memberarea/forums/showthread.php?t=3968) - and I think the discrepancy between CMS and the AMA on what element "Constant" belongs to, is due to symantics...

This is the definition of 'Timing', according to CPT Assistant:
"Timing

Establishing the onset for each symptom or problem, and a rough chronology of the development of the problem, are also important. To do this, the physician may ask; is it primarily nocturnal, diurnal, or *continuous*? Or has there been a repetitive pattern for the symptom? (See also discussion of associated signs and symptoms.) "

So, apparently, they view the word "Constant" as quality, but "Continuous", is timing. What's really confusing about that, is the fact that those words are synonyms:

"*Main Entry:  continuous* 
Part of Speech:  adjective  
*Definition:  constant*, unending"  
http://thesaurus.com/browse/continuous?s=t

So, how the words 'intermittent' & 'constant' became part of 'quality', still doesn't make a lot of sense to me. In my opinion, those words reflect a description of the frequency in which the problem occurs, more than they describe the characteristic traits that are typically associated with Quality (eg, sharp, throbbing, nonproductive, itching, etc.)


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## sullivak (Jul 12, 2012)

I understand your point, Brandi.  It does seem inconsistent.  Here's my two cents worth -

Considering "constant" as a quality of pain makes sense to me.  Perhaps this is because I have actually experienced constant pain before.  Pain that is constant is unrelenting and is particularly crippling.

As far as continuous is concerned, I think of continuous as describing timing - analagous to "throughout the day and night" and not necessarily describing the quality of the pain.  

It is difficult to completely rationalize something as subjective as feelings or sensations.  Hence, the multiple grey areas in E&M, and why physicians themselves describe History-taking as subjective.


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