Coding Corner Answer: Real-Life Rheumatology Note

Take the challenge...

1. C. There are eight possible elements in a HPI; listed below are the ones found in this example:
   1. Associated signs and symptoms—hands tingling and numb
   2. Modifying factors—wearing carpal tunnel braces
   3. Timing—numb at night, pain particularly at night
   4. Location—pain in elbows, shoulders, knees, hips, and ankles
   5. Context—has been ongoing for a year
   6. Duration—an hour of stiffness, pain all day long
2. D. A complete ROS consists of 10 or more systems. The systems reviewed in this example are:
   1. Cardio/vascular
   2. Integumentary
   3. Eyes
   4. Ears, nose, mouth, and throat
   5. Musculoskeletal
   6. Neurological
   7. Respiratory
   8. Gastrointestinal
   9. Genitourinary
   10. Hematologic/lymphatic
   * Notice this note contains the phrase “the rest of her review of systems is otherwise negative.” Not all carriers will accept this; they require that the documentation specifically list all positive and negative symptoms.
3. B. After the original date of documentation, this only has to be updated if there is new information. It is permissible to refer back to the original documentation by stating nothing has changed with the PFSH since it was first taken. If there is an audit of the file, you will have to provide the original documentation of the PFSH.
4. False. Only the physician may take the HPI from the patient, but anyone on staff may take the ROS and PFSH.
5. A. The documentation of a chief complaint must be given for every visit. Some carriers will deny the claim for not meeting medical necessity if the chief complaint is not documented.
6. B. No, a description, sign, symptom or diagnosis must be recorded as the chief complaint even though the visit might be a follow-up visit.