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What's your HPI style?

Discussion in 'Psychiatry' started by FlowRate, Apr 20, 2017.

  1. FlowRate

    FlowRate Physician 7+ Year Member

    Oct 13, 2008
    I've noticed that a lot of people's HPI includes numerous verbatim quotes from the patient. My personal preference, however, is to generally summarize the content of the HPI, only providing quotations when they seem particularly illustrative/important. What's your style? Is there a generally accepted "best practice" here?
    Blessthefall likes this.
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  3. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    I tend to do this too.
    Blessthefall likes this.
  4. Blessthefall


    Sep 16, 2016
    Keep it relevant, detailed yet concise.
  5. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Physician Moderator Emeritus SDN Advisor 10+ Year Member

    Dec 2, 2004
    Left of Center
    Quote as much of the patient's own profanity as possible.
  6. Armadillos

    Armadillos 2+ Year Member

    Feb 5, 2013
    I'm generally much more in the summarization camp, but generally will have some short phrases quoted in there to highlight things. I hate reading huge paragraphs of direct quotes, we aren't court room stenographers, we get paid to gather then interpret information.

    Now something like the below seems like a perfectly acceptable use of quotes to drive a point home:

    Patient reports likely delusional belief that sister is stealing his money out of the bank and wants to "shoot the bitch".
  7. fpsychdoc

    fpsychdoc 2+ Year Member

    Dec 18, 2015
    I like to run the HPI as descriptive and "objective" as possible, leaving my own spin on things to the MSA and the assessment; not necessarily using quotes but paraphrasing a lot and describing behavior. Of course you will have to pick and chose what you think is most relevant. It's probably not the most time efficient way but I also think it would be helpful for whoever is reading the HPI to perhaps come to their own conclusions, so I tend to leave impressions and judgements aside (for example you'd be surprised at what people like to describe as paranoid or delusional. It's not always as clear cut as we'd like to).
    sabine_psyd and MLT2MT2DO like this.
  8. Merovinge

    Merovinge 5+ Year Member

    Aug 9, 2012
    Numerous and long quotes in the HPI has a differential:
    1) Med student
    2) Over inclusive resident trying to impress people with notes
    3) Counter-transference to the patient
    4) Writer feels this case has high likelihood of going to court (not saying this helps, but an impression I get)
    Blessthefall and Liquid8 like this.
  9. erg923

    erg923 Regional Clinical Officer, Cenpatico National 10+ Year Member

    Apr 6, 2007
    Louisville, KY
    -Attempt to demonstrate suspected personality pathology?

    -Attempt to document resistance to or lack of engagement in treatment/treatment recommendations?
  10. clausewitz2

    clausewitz2 7+ Year Member

    Oct 13, 2008
    I remember a guy who I felt could largely be summarized in two direct quotations far more powerfully and succinctly then I could ever devise.

    When asked about employment history: "Do I look like someone who has a job?"

    When asked about what he does to earn a living: "Criminal ****"
  11. erg923

    erg923 Regional Clinical Officer, Cenpatico National 10+ Year Member

    Apr 6, 2007
    Louisville, KY
    Boost that ****, bro!
    Nasrudin likes this.
  12. F0nzie

    F0nzie Physician 5+ Year Member

    Aug 22, 2011
    Still following the words of my IM attending in medical school: "The HPI tells a story..."

    Sent from my iPhone using SDN mobile app
    Nasrudin, Blessthefall and psyxh like this.
  13. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    I got into a fight with my mom and now I'm depressed.
    Nasrudin, F0nzie and Merovinge like this.
  14. thoffen

    thoffen Member 10+ Year Member

    Aug 14, 2006
    Quotes are often very illustrative of pathology that other words cannot capture. I.E. "patient states that he hears the voice of the Messiah telling him that he must 'kill all infidels'" is much more telling than "patient has hyper-religious command hallucinations to kill others".

    That said, people put way too much in the HPI and in particular the subjective portions of progress notes. Develop a really good one-liner (pertinent background and presenting complaint) and tell a brief story. Listing symptoms to me says very little.
    Jules A and Nasrudin like this.
  15. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    I'm curious to what the S or HPI portion needs to contain for billing either a 90204/5 or 99213/4/5.

    Rest of the note appears to be comprehensive enough with modern EMRs, so I don't think this is an issue.
  16. With the ubiquitous sharing of medical records, I am getting more and more concise and vague in my intakes (that's what psychologists usually call them). Pt. reported that father sexually abused her from age 8 to 14 has become pt. reported childhood abuse. I am beginning to move toward only providing biographical information and the minimum of information to justify billing. Our patients' personal story is theirs to tell and it provides very little use to other caregivers. We might want to justify the communication of hx of substance abuse and especially abuse of prescription medications, but I could argue that it is not our role to police that either.
  17. Medical scribe

    Medical scribe

    May 1, 2017
    I like to follow the OPQRSTA method. Not sure if you've heard of it. It straight to the point and keeps me organized. It took me a while months to develop a pertinent hpi. I'm still trying to get it write. It helped me alot. Hope it helps you too. I also developed templates for some recurring pt complaints. I'd be happy to share more thoughts if you'd like.
    O onset
    P palliative or provokative
    Q quality
    R radiation
    S severity
    T timing
    A associative symptoms
  18. splik

    splik Professional Cat at Large Physician Faculty 7+ Year Member

    Nov 30, 2009
    Um yes I think everyone is familiar with this but it's not that helpful for psych. What would you put for radiation?: "His depression radiated out of him and a dense gloom permeated the air..."
  19. Salpingo

    Salpingo 7+ Year Member

    Dec 5, 2008
    It varies from training program, but I was taught that it refers to the type of radiation the patient believes they've been exposed to (e.g. Delusions of passivity/being controlled by electromagnetic radiation is pathognomonic for schizophrenia, while gamma radiation indicates you are most likely treating the Hulk).
  20. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
  21. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Physician Moderator Emeritus SDN Advisor 10+ Year Member

    Dec 2, 2004
    Left of Center
    "Her uterus migrated..."
  22. DisorderedDoc417


    Dec 15, 2016
    If this isn't a troll, I may have to put into question everything I know.

    Blessthefall likes this.
  23. NickNaylor

    NickNaylor Thank You for Smoking Physician Lifetime Donor Classifieds Approved 7+ Year Member

    May 22, 2008
    Deep in the heart of Texas
    I tend to write pretty long notes, so take that for what you will. I enjoy writing notes and can type pretty quickly, so long notes for me aren't a problem. I tend to use as many quotes as possible (and as are relevant to what's going on) in the HPI. I think quotes provide a better picture of what's going on then summaries - not that there's anything wrong with summaries. Ultimately I think the same care can be provided, but quotes help me with a picture of the patient if I happen to go back and read them again in the future. I agree with @F0nzie in that I try and write an HPI that forms as coherent a story as possible, and my HPI is structured in such a way. I typically use the same outline for all of my HPIs:

    Paragraph #1: 1-liner, circumstances surrounding hospitalization (if on an inpatient service), brief summary of hospital course (if seen on a consult), or the problem that resulted in them coming to see a psychiatrist (if an outpatient visit)

    Paragraph #2: information about the chief complaint(s); e.g., if anxiety, then information about the anxiety; if depression, then information about that; if SI, information about that, etc.; any relevant psychosocial stuff also goes in here

    Paragraph #3: psychiatric ROS; the detail of this depends on the patient/presenting complaints but pretty much always includes depression screening, psychosis screening, and anxiety screening; might be more detailed if I'm worried about something else

    Paragraph #4: issues related to treatment - e.g., patient's reported goals for treatment (inpatient/outpatient treatment), issues they'd like addressed by the consult service (C/L patient), treatments they are amenable to doing (medications, psychotherapy, PHP/IOP/substance rehab, etc.) as appropriate and relevant for the presenting issue

    I will typically include more information if there is a safety concern, issues surrounding capacity, or if I'm challenging a historical or presumed diagnosis.
    sabine_psyd likes this.
  24. st2205

    st2205 Attending 10+ Year Member

    Oct 28, 2006
    "His externalization and soul-sucking presence radiated deep to my core causing myself significant despair upon seeing his name on the schedule this morning."
    Jules A and OldPsychDoc like this.
  25. COXblocker

    COXblocker 2+ Year Member

    Apr 12, 2013
    A 99204/5 requires a comprehensive HPI, comprehensive exam, and a moderate/high MDM.

    That breaks down to:
    • a chief complaint
    • an extended HPI
      • 4 elements of HPI or status of 3 chronic or inactive problems
        • Quality = mood
        • Severity = mild,moderate, severe
        • Context = what's causing it
        • Duration = How long has it been going on
        • Modifying factors = anything helped?
      • 10 system ROS (Can be done by questionnaire and transferred to note). My favs are in bold.
      • Constitutional, Eyes, Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
      • Complete PFSH (Need 1 element from each. Can be prepopulated), Favs in Bold
        • Medical Hx:
          • Prior illnesses or injuries
          • Prior operations
          • Prior hospitalizations
          • Current medications
          • Allergies
          • Age-appropriate immunization status
          • Age appropriate feeding/dietary status
          • Extra not for billing, but good to have: psychiatric diagnoses, past medications tried
        • Family Hx:
          • The (mental) health status or cause of death of parents, siblings and children
          • Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
          • Diseases of family members which may be hereditary or place the patient at risk
        • Social Hx:
          • Marital status and/or living arrangements
          • Current employment
          • Occupational history
          • Use of drugs, alcohol or tobacco
          • Level of education
          • Sexual history
          • Other relevant social factors

    • 3 of 7 VS (BP, Pulse, Respirations are easy for MA to get)
    • one element of MSK (gait and station is easy)
    • and psychiatric MSE

    MDM: Moderate requires 3 problem points, 3 data points, and/or a moderate risk issue. High requires 4,4, and high respectively. You only need to meet the category in 2/3, and since there aren't many "data points" to review in psychiatry, the problems and thseverityty of the issue guide the code:
    • Problems
      • 1pt - self-limited or minor (limit 2)
      • 2pts - established problem, stable or improving
      • 2pts- established problem, worsening
      • 3pts - New problem, with no additional work-up planned (maximum of 1)
      • 4pts - New problem, with additional work-up planned
    • Data points
      • 1pt - Review or order clinical lab tests
      • 1pt - Review or order radiology test
      • 1pt - Review or order medicine test (PFTs, EKG, cardiac echo or cath)
      • 1pt - Discuss test with performing physician
      • 2pt - Independent review of image, tracing, or specimen
      • 1pt - Decision to obtain old records
      • 2pts - Review and summation of old records
    • Severity
      • Moderate: One or more chronic illness with mild exacerbation, progression, or side effects of treatment or two or more stable chronic illnesses or undiagnosed new problem with uncertain prognosis (e.g., psychosis)
      • Severe: One or more chronic illnesses with severe exacerbation, progression, or side effect of treatment (e.g., schizophrenia) or acute illness with threat to life (e.g., suicidal or homicidal ideation)
    • Total time face to face with patient
    • "Greater than 50% of face time spent providing counseling and/or coordination of care
    • Counselling provided:
      • diagnostic results or impressions
      • risks and benefits of treatment options
      • instructions for management/treatment and/or follow-up
      • importance of adherence to treatment
      • risk factor reduction
      • Family/caregiver education
      • prognosis
    • Patient/family response to intervention
    • Coordination of care
      • None
      • family/caregiver
      • PCP/outside medical staff
      • School staff/probation
    • Response/outcome of coordination if necessary

    So...a full 99205 note might look like...

    CC: "This is hard"

    Jane Doe is a 23yr old female who states she has been moderately depressed for the past week because she lost her job. She also endorses high levels of anxiety that have worsened with current stressors.

    • Constitutional: no fevers or weight loss
    • Cardiovascular: no palpitations or chest pain
    • Respiratory: no SOB or cough
    • Gastrointestinal: no nausea or diarrhea
    • Musculoskeletal: no joint or muscle ache
    • Integumentary: No rashes
    • Neurological: No headache
    • Psychiatric: depressed, anxious
    • Endocrine: No hot flashes
    • Immunologic: No recent illnesses
    Med/Psych/Family/Social Hx:
    • Appendectomy at age 14
    • 3 admissions to Local Psychiatric hospital for SI/SA
    • Current Meds: Zoloft 25mg
    • Allergies: none
    • Mother: Depression
    • Drugs: Occasional alcohol use
    • BP 120/80, HR 82, RR 14
    • Gait/station wnl
    • MSE
      • Appearance: young caucasian female wearing jeans and t-shirt, well groomed
      • Behavior: Mild psychomotor agitation
      • Cooperation: disclosing, fair eye contact
      • Speech: normal rate, normal rhythm, normal prosody
      • Thought process: circumstantial
      • Thought content: focused on stressors. Denies SI, able to contract for safety. No HI. No hallucinations
      • Mood: "Terrible"
      • Affect: Downcast, full range, non-labile, congruent to mood
      • Perceptions: intact
      • LOC/Knowledge: appears adequate
      • Insight: fair
      • Judgment: fair
    • Unspecified mood disorder
    • unspecified anxiety disorder
    • Cluster B traits
    • Increase Zoloft to 50mg daily
    • Provided supportive therapy
    • Refer to psychology for continued therapy
    MDM Risk: High
    Total time face to face with patient was 60mins
    Greater than 50% of face time spent providing counseling and/or coordination of care

    Counselling provided:
    • Diagnostic results or impressions
    • Risks and benefits of treatment options
    • Instructions for management/treatment
    • Importance of adherence to treatment
    • Risk factor reduction
    • Prognosis
    Patient/family response to intervention:
    She agreed with the assessment and prognosis as discussed. She understood the need for continued treatment and therapy. She agreed with the medication changes and understood the need adherence. She understood the need for interventions to reduce further harm.

    Coordination of care
    • PCP/outside medical staff: Referral placed
    Response/outcome of coordination if necessary:
    • Pending approval for outside therapy

    This note documented everything necessary. With an EMR that pre-populates much of the data and allows a drop down for the MSE, this would take <5mins to write. Of course, if the nature of the conversation needs some CYA extra stuff that's fine, but I think this sparse, mostly EMR generated, almost useless note to get paid appropriately lets you actually sit and talk with the patient.
    neoevolution likes this.
  26. hamstergang

    hamstergang may or may not contain hamsters 5+ Year Member

    May 6, 2012
    If you include this line and the total time, then you're billing based on time and none of the elements from the history, exam, or MDM are needed.
  27. michaelrack

    michaelrack All In at the wrong time Physician SDN Advisor 10+ Year Member

    Dec 22, 2007
    Memphis TN
    why not just do a 90792? slightly more rvu than a 99205. a little less documentation required for 90792.
  28. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    Comm ins takes it I believe, but CMS doesn't allow it. I think insurers are starting to phase this code out IIRC. I could be wrong about it being phased out but I do know that CMS doesn't accept it.
  29. st2205

    st2205 Attending 10+ Year Member

    Oct 28, 2006
    You could add 90833 to the 99205. Not sure how many people do.

    My training institution we're all billing 90792. Where I'm heading I plan to switch to 99205 but this far billing all new encounters with Medicare/Medicaid as 90792 I have never been told we weren't getting reimbursed, whereas they've hounded me for stupid nuances of ICD10 codes.
  30. michaelrack

    michaelrack All In at the wrong time Physician SDN Advisor 10+ Year Member

    Dec 22, 2007
    Memphis TN
    I haven't had any problems so far getting 90792 reimbursed by CMS, but I am going to double check with my billing person for my practice, as well as the billing person for my employed position. My guess is that certain CMS carriers/regions may not allow it; but I believe it is still covered by medicare in general
  31. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    Quite possible that is my case where the CMS carriers in my area are not allowing this code.

    I'm wondering, what's the chance for billing 205 for all new vs 204 being audited?
  32. st2205

    st2205 Attending 10+ Year Member

    Oct 28, 2006
    If you've got all the documentation what are they going to do? I wish we'd stand up a little more to the nonsense by not letting them intimidate us into billing for less.
  33. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    The audits and then the fighting. Can get ugly. Esp with CMS.
  34. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING 7+ Year Member

    May 20, 2010
    Everyone learns this in second year of medical school bud...and then learns this format, while helpful for initial structuring, has very limited utility.
  35. Daedra22

    Daedra22 7+ Year Member

    Nov 20, 2009
    I try to write a relatively straightforward narrative which does sometimes include a number of quotes. I tend to do this more if the quotes support some portion of the mental status exam and/or if I'm on the inpatient unit and we might be looking towards commitment. I might also do some quotes for my outpatients if it's something I want to remember for future encounters (i.e., if someone has a word they associate with some behavior or feeling that I don't often use).
    Jules A likes this.
  36. Jules A

    Jules A Classifieds Approved

    Jun 6, 2016
    I do 205 for all intakes and have never been asked by my admin staff to provide any further information indicating they were being contested so I assume they are being paid. I was taught to be aware of the bullet points needed for the different levels and address them rather than simply billing lower in an effort to avoid scrutiny.
  37. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    I wonder if you'd be willing to work privately with redacted information as to improve my own EMR experience.
  38. Jules A

    Jules A Classifieds Approved

    Jun 6, 2016
    Hopefully some of the uber bad ass, experienced psychiatrists here will respond because I'm in no way especially skilled at documentation. I'm about middle of the road with regard to amount of content largely because I have almost no patience for reading long, flowery notes which often either seem to pad the writer's ego or set them up with additional legal fodder so I attempt to be succinct.

    I initially reviewed a list like COXblocker added and the EMRs I use have templates set up to basically spoon feed the data needed. Hopefully others will write if this isn't the case but in all my notes I do a minimal blurb on vitals, labs, pain, sleep, appetite with the stock "remaining systems wnl" and to continue with therapy which is not especially time consuming and I believe helpful to support billing code.

    Like you mentioned I also wonder if different areas have different level of CMS attention?
    Shikima likes this.

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