Wiki NEED HELP to settle a dis agreement on HPI

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Justarose

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The question is really simple ...

Coding for physician practice ... E/M

When doing the HPI - he says she "denies ab pain, diarrhea, coughing, ect... "

Can the DENIAL of signs and symptoms be counted as an HPI element ?


Please help ... Thanks !

Also can anyone tell me WHERE I might find the answer whatever it might be ?? :eek:
 
I include negatives as Associated Signs/Symptoms

Yes, I sometimes includes negative responses as associated signs/symptoms. Sometimes they are ROS.

Depends on what the patient is being seen for. If the chief complaint was "hurt her ankle" then I wouldn't count "denies ab pain, diarrhea or coughing" as associated sign/symptom, but ROS. If the chief complain was "nausea" ... then the ab pain and diarrhea (even negative) could be considered associated signs/symptoms. The cough? ... probably ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
If they relate to the problem, you can usually use them in the HPI. However, there were, for a time, some payers not accepting negative symptoms as symptoms. So, it can't hurt to check with your top payers.
 
The credit given is for the time it takes the doctor to obtain the information and record it in the record. When the answer to a question is "no," this does not negate the effort required to obtain and document the response.

The April '96 CPT Assistant says regarding "Associated Signs/Symptoms" that "a clinician may ask patients directly about 'pertinent positives and negatives,' such as..."

The CMS E/M Guidelines specifically refer to documenting "pertinent negatives" in relation to the ROS.

Never has CPT or Medicare at the federal level indicated that "credit" was only supposed to be given when the answer to a signs/symptoms question was "yes." Doctors are still expected to document the "no's" and this should be credited.
 
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