Ok...well auditing can be subjective, and some of the guidelines are grey...so you may get varying responses...and here's my two cents.
You can have two locations within an HPI if the two problems are unrelated (sore throat and ankle injury).
When it comes the term headache, I would not give credit to two spots in the HPI for this one word.
"Ache in the head"...different story.
Careful with that "two locations" thing. I think there may be ONE Medicare carrier that allows us to count it that way. The rest will say that every one of the 8 HPI elements can only be counted once, regardless of how many times that HPI element can be counted in the HPI statement.
As to the original question question (regarding how to count the a presenting problem of "headache x3 days"), I would only count location and duration for that statement. Some folks might try to stretch that and say that "ache" is a quality statement. Yes, "ache" or "achy" can be a quality statement in SOME clinical contexts. But not this one. What you know from this statement is that the pain is in the head (location) and that it's been going on for 3 days (duration). We don't know anything more than that from this statement. If you were looking for a quality statement related to a presenting problem of headache, you'd see something like "dull", "sharp", "feel like a band around my head", "feels like a knife", etc. In other words, it would be an adjective that describes the type of pain.
The reason "headache" wouldn't be counted as an associated sign/symptom (instead of lcoation) is that there's nothing to say what the headache is related to. If the patient sustained a head injury in a fall and was now complaining of a headache, in THAT context, headache would be an associated sign/symptom. But if the patient is complaining of a headache and you don't have any other symptoms that one might associate with a headache (blurred vision, nausea, ringing in the ears, sensitivity to noise, etc), then all you've got is the location of the symptom.
One thing we can't forget when we're auditing is that counting HPI elements isn't about sticking word phrases into boxes. We MUST look at what's written from the perspective of what the doctor is looking at in his/her assessment of the patient (ie, we must look at the information from a clinical perspective).
Interestingly, in my 12+ experience in auditing, I've found that if we look at what the doctor wrote from a clinical perspective (rather than from a "just count the elements" perspective), much of the subjectivity in E/M auditing goes away. For example, the example given by Karolina (headache and sore throat) - did you know that having a headache is one of the 4 classic symptoms that is present in a patient who is positive for strep throat? Asking a patient who presents with a sore throat whether they also have a headache is a classic example of an associated sign/symptom question for a sore throat presentation.
Karolina, I don't mean this to sound like I'm picking on you. I'm just trying to point out that when we count our E/M elements, we need to think like the doctors are thinking. Otherwise, we're going to end up counting things we shouldn't (or missing things we should count).
JMHO....
Joan Gilhooly, CPC, PCS, CHCC
Medical Business Resources, LLC
