Coding Guidelines, E/M Coding

Quick Guide: Elements of HPI For E/M Coding

Okay, I’m the first to admit that I don’t like coding E/M. When I was first starting out and looking for coding jobs, I would do my best to avoid applying for anything that had any E/M mentioned in the job description. I ultimately lucked out, and got into radiology coding, which I love. Then later when I moved on…guess what my first assignment was–doing an E/M audit! I was lucky (again) that I had wonderful coworkers to help me along the way. But I do distinctively remember crying over it one day while working on it. It just wasn’t my thing. But over time, that has changed (a little bit) and now I  can do an E/M audit with less problems (and less crying). But it still is confusing and every time I work on anything E/M, I have to review everything to refresh my memory.

One part that I think can be a little confusing is going over the HPI and counting up the elements. In theory, you would think this would be the easy part. Maybe it is for some people, but not for me. So I review this and it helps, so I thought I’d share it here. This comes directly from the CMS website:

History of Present Illness (HPI) HPI is a chronological description of the development of the patients’ present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

 

  • Location (example: left leg)

 

  • Quality (example: aching, burning, radiating pain)

 

  • Severity (example: 10 on a scale of 1 to 10)

 

  • Duration (example: started 3 days ago)

 

  • Timing (example: constant or comes and goes)

 

  • Context (example: lifted large object at work)

 

  • Modifying factors (example: better when heat is applied)

 

  • Associated signs and symptoms (example: numbness in toes)

 

SOURCE: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf 

So, that’s it! Does this list at least help a little bit? I could attempt to go on and on about E/M and try to explain it in more detail, but I don’t want to confuse anyone even more. I feel like E/M is something that can only be learned by coding practice cases or just learned over time. I will share the audit sheet I use though. It is from Novitas and you can find it here. Please note though–this is the 1995 guidelines.

If you’re looking for the 1997 guidelines/specialty exam score sheets, go here.

These are by no means the only score sheets available. This is just what I personally use, so I thought I would share it on the blog.

 

Thanks for reading,

Lindsay

 

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Coding Guidelines

Can You Code Symptoms And A Definitive Diagnosis Together?

If you’ve been an outpatient coder for a while, you may know the answer to this off the top of your head. However, if you’re new to coding, you may not, so I thought it would be helpful to go over this guideline real quick. Before we even get started, I just wanted to say that as a general rule, in outpatient coding, you would not code the symptoms and the findings together. For example, let’s take a radiology coding example because I admit I’m biased and it’s my favorite. Say if a patient goes to get an x-ray of their elbow for pain, and it turns out, they have a fracture, you would code the fracture and not the pain, since the fracture is the finding. Pretty easy, right? But there is a guideline that I admit, I didn’t really even think about until not that long ago. You can turn to it in your ICD-10-CM book. It is in the front of the book in the guidelines, for chapter 18, b. Here is a pic just to make it easier:

 

So basically what this guideline is saying is that sometimes you can assign symptoms when it’s not associated with the definitive diagnosis. You would code the diagnosis first, then the symptoms. This is something I don’t see too often in radiology coding. Is this something you’ve coded before? Does anyone have an example they can share? Anyway, then it goes on to say that signs and symptoms associated with a definitive diagnosis are not coded with the diagnosis. This is the part that most coders seem to know.

Anyone have any comments on this? Examples? Please share in the comments below.

 

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