I find this hilarious. The E&M rules of documentation state very clearly what type of information is required on follow up cognitive care visits. What is required in order to get paid. The rules of HPI (History of present illness) state that you need to include things like character, onset, location, duration, what makes it better or worse, associated signs or symptoms. These are the stated requirements for follow up visits. If you have 4 or more elements, you get a high level component, and there for higher payment rates.
This is all fun and dandy when you can quantify a complaint. What are some examples that you can quantify?
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Successful software implementation starts with choosing the right system. This checklist contains over 50 of the most important features to look for when evaluating:
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These are things you can quantify and clarify. But what do you do when a chief complaint does not involve a qualitative or quantifiable entity. There are no E&M rules that allow exceptions to these circumstances. So you get the following garbage:
Chief Complaint: Hypercalcemia
HPI: She presented with hypercalcemia. It is described as chronic, constant, and parathyroid. The symptom is gradual in onset. The symptom started during adulthood. The complaint is moderate. Significant medications include lithium. Important triggers include no known associated factors. The symptom is exacerbated by dehydration.
What you have just read is an actual patient encounter for the HPI of hypercalcemia. If this isn't a total pile of garbage, I don't know what is. There is not a single piece of information in that excert that was clinically worth anything. In fact, it reads as if it is computer generated with key word insertion.
Character: Moderate (what does that mean)
Onset: adult hood (what the hell)
Location: parathyroid (seriously?)
Duration: chronic and constant and gradual in onset.(what a bunch of garbage)
What makes it worse?: nothing and dehydration in the same paragraph, completely contradicting each other.
Imagine how much time was spent entering this worthless information. Not only asking them but entering them into the computer. Imagine multiplying this by 25 times a day. And you wonder why health care is so inefficient. Because we have to ask completely meaningless questions to get paid. Instead of practicing medicine, we are forced into inefficient processes to get paid for following these ridiculous rules of engagement.
"It started during adulthood" The fact that my patient is middle aged makes that very statement hilarious and clearly template driven compensation based medical care. And we have no other way but to follow the rules.
You can see much more in my free lectures on medical billing and coding.
This is all fun and dandy when you can quantify a complaint. What are some examples that you can quantify?
- pain
- rash
- shortness of breath
- headache
- abdominal distention
- weakness
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- electronic medical records
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Other useful information is available at my EHR Resource Center. Chief Complaint: Hypercalcemia
HPI: She presented with hypercalcemia. It is described as chronic, constant, and parathyroid. The symptom is gradual in onset. The symptom started during adulthood. The complaint is moderate. Significant medications include lithium. Important triggers include no known associated factors. The symptom is exacerbated by dehydration.
What you have just read is an actual patient encounter for the HPI of hypercalcemia. If this isn't a total pile of garbage, I don't know what is. There is not a single piece of information in that excert that was clinically worth anything. In fact, it reads as if it is computer generated with key word insertion.
Character: Moderate (what does that mean)
Onset: adult hood (what the hell)
Location: parathyroid (seriously?)
Duration: chronic and constant and gradual in onset.(what a bunch of garbage)
What makes it worse?: nothing and dehydration in the same paragraph, completely contradicting each other.
Imagine how much time was spent entering this worthless information. Not only asking them but entering them into the computer. Imagine multiplying this by 25 times a day. And you wonder why health care is so inefficient. Because we have to ask completely meaningless questions to get paid. Instead of practicing medicine, we are forced into inefficient processes to get paid for following these ridiculous rules of engagement.
"It started during adulthood" The fact that my patient is middle aged makes that very statement hilarious and clearly template driven compensation based medical care. And we have no other way but to follow the rules.
You can see much more in my free lectures on medical billing and coding.
Don't know what kind of EMR generated this HPI, but the template obviously kind of sucks. Not that ours is fantastic (sometimes you see the same 12 groups of words all day long as part of the physical exam, for instance), but I don't think our EMR is particularly restrictive about HPI. I've seen myriad paragraphs and all sorts of interesting (and at times peculiar) HPIs. Perhaps this is one of the downsides to using an EMR...a sort of loss of creativity and personal touch to the contents of medical records. The upside, however, is that EMRs are always, without exception, perfectly legible.
ReplyDeleteI think part of the problem with HPI is that it can be so subjective for various reasons, perhaps because of poor quality of information received from the patient or because there is so much information that you don't know which would "fit nicely" into the EMR. When I first started, HPI gave me fits because it can be so impossible to decipher. But now that I understand it and have seen the variations it can take, it's not such a headache anymore. Sometimes it's the most interesting part of the note.
I had similary problems when I was a sleep fellow evaluating osa patients. If I wrote "the patient has snoring, restless sleep, morning headaches, witnessed apneas,morning dry mouth, and awakenings gasping", the coding auditor would count all those as associated symptoms.
ReplyDeleteI got around this by making snoring or sleepiness the chief complaint and writing something like "the patient reports mild sleepiness,for 3 years, gradually worsening,worse in the morning, associated with snoring"