Wiki Calling all auditors! NEED HELP!

[carriganm]

Hello there!

I have a provider in our office that I struggle so much with her HPI's. She will list the labs drawn and the results next to them. Occasionally listing meds taken. Below is an example. I have been told that I can't count these as status of 3 conditions because it is out of the scope of the coder to determine which conditions these labs are associated with as well as determining whether they are stable, improving, ect. Which I totally agree with. Here is an example of one I am having a hard time with.

Pt. presents today in f/up on labs.

Discussed labs drawn on 7/5/17
CMP: Glu 108 otherwise wnl.
A1c: 5.6
Insulin: 17
TSH: 1.33 Takes levo 137 mcg and lio 10 mcg
fT4: 0.92
fT3: 2.6
Lipids: 112/119/57/31 Takes atorvastatin 40 mg.
CBC: wnl

Pt has seen a health coach a couple of times. Will set her back up with her.
Pt. is sxic (very fatigued) and fT4 is low, fT3 is low normal.

So she listed the date the labs are drawn, can this be counted as timing? (I don't think so, but another coder counts this in our office)
Also she lists two different meds which by the looks of it is for two completely different conditions. Do I get 2 points for this for modifying factors? Or just one?
Very fatigued. I am counting this as associated signs and symptoms.
Then she reiterates that the Ft4 and Ft3 are low and low normal. Can I count this as quality?

Thank you for any help you can give. I have tried giving her pointers to make her HPI's better but she doesn't seem to make an effort.

 

[Chelle-Lynn]

To answer the series of questions:

- Can the date of the lab draw be counted for timing? Timing is for the time of day, for example; always sick in the morning, becomes tired in the afternoon, wakes up often at night, etc. Duration would generally not be used either (although this is subjective) as it is not referencing the length of time of an illness or condition

- For history: to allow for modifying, the information would need to come from the patient indicating if they feel better, worse, the same based on the use of the medication. The documentation below appears to be from the provider so it is not eligible for HPI. If the information was from the patient you can only receive 1 point for each category so it would never be 2 points. Unfortunately the note in regards to the health coach did not indicate if the sessions modified any condition or issue so it cannot be counted either.

- Very fatigued would be correct as a sign or symptom.

- FT4 and FT3 as low and low normal would be part of the MDM for review of labs, again the information did not come from the patient.


General rule of thumb for determining where to allow for the various documentation:

HPI - Comes from what the patient tells you
EXAM - Comes from the hands on of the provider
MDM - Comes from the providers interpretation and findings based on the HPI and Exam.