Wiki HPI question for oncology

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Karolina

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Hello Fellow E/M coders/auditors:

I am currently seeking opinions about assigning HPI for the scenario below:

In the providers' notes many times we see, “43 yo F with recently diagnosed ER+/PR+/HER2+ Stage III invasive left breast carcinoma, on adjuvant AC-TH.”
We would assign the HPI elements:

Quality: ER+/PR+/HER2+
Severity: Stage III invasive
Location: Left breast
Modifying Factors: on adjuvant AC-TH

When the patient returns in a few weeks for treatment, and this statement is copied in, can this information be used again to code the 4 HPI elements?

Opinions within my department differ. Some of us say yes and some of us feel that the HPI should come from the “interval history”.

Your opinion/s will be greatly appreciated!
 
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Karolina said:
Hello Fellow E/M coders/auditors:

I am currently seeking opinions about assigning HPI for the scenario below:

In the providers' notes many times we see, “43 yo F with recently diagnosed ER+/PR+/HER2+ Stage III invasive left breast carcinoma, on adjuvant AC-TH.”
We would assign the HPI elements:

Quality: ER+/PR+/HER2+
Severity: Stage III invasive
Location: Left breast
Modifying Factors: on adjuvant AC-TH

When the patient returns in a few weeks for treatment, and this statement is copied in, can this information be used again to code the 4 HPI elements?

Opinions within my department differ. Some of us say yes and some of us feel that the HPI should come from the “interval history”.

Your opinion/s will be greatly appreciated!
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My answer would be yes. Isn't it still the HPI? What has changed since the last visit? Is the breast cancer being treated and is that the follow up? I thought interval history is used for inpatient.
I'm interested in other coders views.
 
Yes because it is still the history of the disease she is currently being seen/treated for, regardless of what has happened since that time.

I'm in a physician practice. Most of our doctors document the full history at the time of their consult then dictate an interval history at the first follow-up. At the second follow-up, pertinent elements of the interval history are moved into history so it is current through that first follow-up visit and the interval history changes to reflect the time period between the first and second visit. And so on and so on.

Are you a hospital-based or physician-based coder, Karolina? I think that will make a big difference in the responses you get.
 
Yes, I would still accept as long as it is still current. Obviously, if anything has changed, I would expect the provider to update the info.
 
This is just my opinion based on many external audits working in several Oncology practices over 12 years.

The HPI is to be recorded for each encounter, not carried forward.
HPI can only be recorded by the physician.
It is the subjective information, typically in the patients own words.
a. Initial visit: from the onset of symptoms to the present.
b. Follow up visit: from the previous visit to present.

Interval history simply means from the last time the provider saw the patient to present, interval history by CPT would eliminate the need for PFSH documentation which applies to subsequent visit CPT codes only.

I would be hesitate to give an extended HPI (4 element credit) to the above information entirely. It's hard to determine whether the patient is actually being seen or records reviewed by the provider in the above information. A patient rarely speaks so medically with a provider, it reads as objective information mostly.
 
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