Urology Coding Alert

If your provider is struggling to document enough history of present illness (HPI) for his pre-vasectomy encounters, he may be doing the work but just not writing it down. Help your provider fully (and accurately) document his work, by reviewing the following common HPI notes that your urologist might be missing. 

“The HPI seems to be the area coders get hung up on,” Gross says. “The following have been suggested as HPI elements, which we use.” 

Location/CC: Vas Deferens

Duration: How long has the patient been thinking about a vasectomy? “This is important because we need to know the patient has thought the procedure through,” Gross adds. Asking how long the patient has been married can also count toward duration.

Severity: How many children does the patient have?  “It sounds harsh to use the term ‘severity’ but this element shows to what extent the patient’s fertility has been utilized,” Gross says.

Modifying factors: Type of birth control the patient and his partner have been using to prevent pregnancy

Associated signs and symptoms: Erectile function, any pain/anomalies in the affected area. “There is a chance the patient’s erectile function could be affected by the procedure, so the quality of his erections should be known prior to the procedure,” Gross explains. “Also, any pain/anomalies the patient has could make the procedure more difficult or cause complications, and it’s imperative these are documented if they are present.”

Remember: For a comprehensive HPI, your urologist must document four elements in the medical record.