Internal Medicine Coding Alert
You Can Give 'Negative' Credit Under HPI
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? Example: A patient presents with complaint of nausea. The note states that the patient has no fever. Should I check the associated signs and symptoms box, since the provider asked but the response was negative, or is no credit assigned?
Florida Subscriber
Answer: Negative responses can count toward the history of the present illness (HPI) just as they do toward review of systems (ROS) questions.
Remember that HPI as gathered by the provider to create a clinical picture of the most likely diagnosis. So the patient's answers, whether positive or negative for particular signs and symptoms, provide the puzzle pieces from which the internist is able to formulate his assessment and plan.
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