Wiki calculating the HPI level

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Colliemom

Colliemom

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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!
 
twizzle said:
....and context; found on colonoscopy.
Click to expand...


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.
 
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.

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.
Click to expand...

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.
 
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.
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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'
 
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'
Click to expand...

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.
 
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?
 
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.
 
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.

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

Hope this helps.
Click to expand...


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.
 
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.
 
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.
 
HPI elements

stephanie.moore@wdhospital.com said:
Excellent !! My mistake.

Have a great day!
Steph
Click to expand...

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.
 
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.
 
HPI elements

ellzeycoding said:
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.
Click to expand...

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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