Wiki Can you infer the location in HPI?

[alannae]

This is the HPI section of the note I am reviewing:

85yo female referred by Dr. ____. Patient with history of ulcer. Patient with lifelong anemia. Patient unable to tolerate oral iron.

Here's how I've graded this section:
history of ulcer - associated s&s
lifelong - duration
anemia - inferred location blood????
oral iron - modifying factors

Am I pushing to hard to get to 4??

Thanks!

 

[MnTwins29]

Is blood a location? If a location is inferred, I would believe it would be stomach/GI with the intolerance of iron and the history of ulcer. However, I wouldn't be too comfortable with going there.

 

[dclark7]

The HPI should relate to the reason the pateint is being seen. If the pateint is being seen for anemia then how is a history of ulcer a related sign or symptom? I'm with Lance as far as location. I think you are pushing too hard to get 4.

 

[MikeEnos]

To answer your question: yes - you are pushing too hard to get to 4 HPI elements. This is a brief HPI.

Regarding the question of whether or not location can be inferred - this is an excellent (and controversial) question. Unfortunately I don't think you will get a definitive answer here, you will have to check with your local carrier for guidance. If you do get anything in writing, please post it here.

Some carriers do allow you to infer location. So for example, anemia - blood, depression - brain. Other carriers DO NOT allow you to infer location. Here's a quote from WPS Medicare:

Q 5. When a patient presents at the office for ongoing monitoring/evaluation of a condition such as diabetes or hypertension is location inferred, given there is no specific anatomical location for these disease processes?
A 5. Location is part of the History of Present Illness (HPI). A provider may not infer a location. The location element of the HPI would be a definitive location on the patient's body. Choose a brief or extended HPI based on the documentation.

I can't independently verify this one, but Laura Lovett, CPC, CEMC posted this on the AAPC forums a few years ago:

I have the original document where they posted in December 2008 that you can infer location. Also I attended an E/M lunch time learning they gave over June and July of this year, they said it was ok then too, but they gave several clearly wrong answers as well so who knows.

This is the statement in the original document

"3. Is it appropriate to infer location for a psychological or psychiatric chief
complaint?
Yes. The location (of brain) can be inferred from a psychological chief complaint.
Location is the site of symptoms or where the problem is located."

 

[sdelth4284]

I asked this question of Novitas recently and received a response. I am curious about how others interpret their response. I've asked other coders and the interpretations are mixed.

Question: I understand that a description of left arm pain is a clear location. May a coder infer a location that a provider documents with a diagnosis or condition such as diabetes? For diabetes the location is endocrine system. Another one could be depression with a location of brain.

Novitas' answer: If you are billing for something such as diabetes or depression and there is not a specified location, it is best practice for location HPI to select the most appropriate general location for the diagnosis being billed. More information on the HPI guidelines can be found by following the link below.

The link was for the 1995 guidelines.