HPI For Diabetes, Fatigue, Hypertension and Medical Management.

The history of present illness (HPI) is a standard component of a medical interview along with a review of systems and a physical exam. A loyal reader of mine introduced me to the concept of how to document the HPI without ever seeing the patient.    You can use this technique for such conditions as diabetes, hypertension, fatigue and hospitalist to follow consult requests.  This  type of documentation describes 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 (E&M) related medical billing and coding for physicians to get paid without being accused of fraud.

Technically speaking, Medicare requires a face-to-face encounter for all evaluation and management visits, even though E&M documentation requirements for some visits can support accurate coding without an obvious charted experience.  I never knew meeting the four elements of the 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?   Every third year medical student knows  the  medical components of HPI are:
  • Character
  • Onset
  • Location
  • Duration
  • What makes it better or worse
  • Other associated signs or symptoms
To bill the highest level hospital follow up, one must document at least four elements of the HPI listed above.   The reader sent me several examples of how documentation can support that requirement  while I hyperbolized my own reference to medical management consultation.  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: 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.
And another:
Chief Complaint/HPI:  HTN.  He rates his symptoms as none.  He's had this problem for 8 years.  He gets symptoms never.  They don't occur after anything.  Not taking blood pressure medicine makes it worse.  Taking blood pressure medicine makes it better.  Associated symptoms include none.  
And another:
Chief complaint/HPI:  Hospitalist to follow post op.  The patient is post op.  It started one hour ago.  The location is his abdomen. His duration of post op is forever and ever, starting one hour ago.  His post op state is made worse by an incomplete standard order set.  His post op state is made better by the general awesomeness of his hospitalist team who was asked to follow post op on a patient with no chronic medical problems.
I never knew the chief complaint of  diabetes, fatigue, hypertension and hospitalist to follow consults  could fulfill all four elements of an HPI.  As a hospitalist, I get my fair share of these types of consults.  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, especially when I get a chance to rush down to the post op recovery area and do the consult while the patient is still yelling confused profanities at the post operative nurses.    I am going to have to start using this line of questioning on all MY patients too. Unfortunately, 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 also carry my own original pocket E/M reference card shown below.  


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

Click image for high definition view

And of course, a little HPI humor from The Happy Hospitalist's original collection of crude E-card comedy.

"Your History of Present Illness is giving me illness.  Just so you know..."

This e-card is for entertainment purposes, the humor of which may only be understood by certain healthcare professionals. Read at your own risk.

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