Internal Medicine Coding Alert

Question: I have found information and heard at seminars conflicting information regarding the Associated Signs and Symptoms in the HPI section of the 1997 audit guidelines. Does a negative response count toward the HPI points? For example, say a patient presents with complaint of sinus pain. The note states that the patient has no fever. Because the provider asked about the symptom and the response was negative, should I check the associated signs and symptoms box, or should I assign no credit?

Colorado Subscriber

Answer: The lack of fever represents a pertinent negative in this example, but not under the history element you think it does. The 1997 "Documentation Guidelines for E/M Services" does not reference pertinent negatives in the context of the history of present illness (HPI). Instead, it references pertinent negatives in the context of the review of systems (ROS).

Impact: When the note contains a pertinent negative, such as the patient has no fever, do not check the associated signs and symptoms box of HPI. Instead, you should count the statement toward the review of the relevant system (constitutional symptoms, e.g., fever in this example) under the ROS, because this is a pertinent negative for ROS.