Wiki E/m hpi

[phycoder]

Really quick question..... we are having interoffice 'discussions' on this and I am looking for outside opinions.

A patient comes in for pruritus. HPI states info regarding that symptom. Detailed exam is done as patient also has hypertensive kidney disease and DM. Those two issues are discussed in the assessment and plan. The provider billed out a 99214 and one coder wants to down code because the prov did not list the chronic diseases in the HPI


this is the hpi:

History of Present Illness

Patient is 78-year-old female who is coming in today with complaints of itching. She reports that she has itching mostly that is worse at night. She has a history of itching particularly when she is very anxious. If this is caused her to have significant insomnia. She has tried hydroxyzine with no resolution of her symptoms. She denies any chest pain or shortness of breath. He denies any particular areas of a rash.

Note the patient also has a history of a gastric polyp and also non-Hodgkin's lymphoma. The patient reports to me that she has been recommended by her oncologist to have a repeat EGD. However the patient is very anxious about having this repeated as she had complications after her last EGD. As of now the patient has made a decision not to have a repeat EGD. However per the reports that I am reading the mass has grown daily double in size in her abdomen.


and this is the assessment/plan

Assessment/Plan

1. Pruritus
This may be secondary to anxiety given her current illnesses. I will try her on triamcinolone lotion to see if this will help with the pruritus. We will also treat her with Ativan low dose to see if this will help with some of anxiety as well.
2. HTN - Hypertension
Stage II today. We will continue to monitor
3. Chronic kidney disease
Aware. There are no new changes. She is aware that she cannot take any anti-inflammatory therapy.
4. History of gastric polyp
As noted above. She has clotting EGD for now.
5. Non-Hodgkin lymphoma
Followed at the cancer center.
6. Type 2 diabetes mellitus
Her last hemoglobin A1c was 8.3%. She is on insulin therapy. We will continue to monitor her glucose and also encouraged her to modify her diet. Follow-up in several weeks

 

[stampinriz]

Regardless of whether or not you allow credit for the Hypertension or CKD, there is still enough documented to support a 99214 (assuming the ROS & PFSH support a detailed history also). Although these conditions are not specifically mentioned in the HPI, if a BP was obtained as part of vitals, then I would allow this dx. If no BP was obtained, I would not count the HTN. The CKD seems to be playing a role in the MDM since it is mentioned the patient cannot take anti-inflammatories, so I would allow this diagnosis as well. Hope this helps some.

Also, even though I would allow these, I still would give the physician some education on capturing chronic conditions in the History to ensure his/her record is above reproach.

 

[thomas7331]

I would not penalize a provider for the fact that a chronic condition was not included in the HPI. Providers are required to consider all of a patient's conditions when managing a problem, prescribing new medications, etc. There is no coding or documentation requirement that these be discussed in the HPI in order to be counted. The chief complaint and HPI in this case may just be pruritis (and anxiety), but the existence of those other conditions does make the formulation of treatment plan more complex and supports the medical necessity of coding this at the higher level. Agree with the previous post that a notation somewhere in the history that the provider has reviewed and updated any history or chronic conditions would be a good idea for quality documentation, but I would not find fault in the provider's documentation and coding for this visit - I think that would be overreaching.