A loyal reader of mine has introduced me to the concept of how to document the HPI without ever seeing the patient. This is the type of documentation that occurs for describing information that has no therapeutic value for patient care and no communication value for other physicians or health care providers reading the chart, but meets all the criteria set forth for evaluation and management medical billing and coding.
The only purpose of this documentation is to get paid by the Medicare National Bank. I never new that meeting the 4 elements of the History of Present Illness (HPI) could be so easy in a face-to-face patient encounter that could have been done while driving down the interstate on the way to Disney. What are the elements of an HPI? They are the descriptive elements of the history of the present illness. As every good third year medical student knows, these are the components of HPI:
- Character
- Onset
- Location
- Duration
- What makes it better or worse
- Other associated signs or symptoms
To bill the highest level hospital follow up (99233) or hospital admission codes (high level admission 99223, high level observation 99220, high level admit/discharge same day 99236), you must document at least four elements of the HPI as listed above.
The reader sent me several examples of how the documentation game can be played to full effect. Here are several examples of home visits submitted for payment that include at least four critical elements of HPI that makes this documentation meet the highest criteria.
I never knew charting could be so easy for home visits:
Chief Complaint/HPI: Mr Smith presents today for the following conditions: Diabetes. He rates symptoms as severe. This problem has been ongoing for 15 years. The symptoms occur after eating. This occurs after illness. It is worse with immobility. It is better with losing weight. Associated signs include anxiety, confusion and decrease in mobility.
Here is another
Chief Complaint/HPI: Fatigue. Mr Smith presents with the following conditions: Fatigue. The patient rates their symptoms as severe. This problem has been ongoing for 12 months. The symptoms occur after illness. This occurs constantly. It is worse with obesity. It is better with losing weight. Associated signs include decrease in mobility.
I never knew the chief complaint of diabetes could fulfill 4 elements of an HPI. As a hospitalist, I get my fair share of diabetes consults (CPT® 99253, 99254, 99255). I prefer to use the status of three chronic medical conditions in place of the 4 HPI requirements. Or better yet, I prefer to document HPI and ROS unobtainable. Although, if it really is this easy, I am going to have to start using this line of questioning on my patients too. It's unfortunate, but we live in a health care environment where EMRs manage doctors, E/M manages the documentation and patients are managed by Groupons selling 70% off deer hoof extract (locally grown of course) at the Chiropractor.
Just once, I'd love to see Medicare offer physicians a Groupon for 100% off E/M day, where we could just document what's important to patient care and get paid for the work we provide and not worry about how many points we accumulated in the data portion of the medical decision making component of the 2/3 rule for history, physical and medical decision making. I guarantee you wouldn't see the nonsense above.
If you want to get paid in this crazy Medicare world of evaluation and management, you have to understand the 1995 and 1997 CMS guidelines for documentation. It's why I carry my own E/M pocket reference card. Follow the link to get yours today.
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Other useful information is available at my EHR Resource Center. LINK TO E/M POCKET REFERENCE CARD POST
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