Severity element of HPI can be defined in many different ways

Q: I have been asked to review some of our physician notes, and I was hoping that you could clarify for me the different elements of the history of present illness (HPI).

A: An essential part of evaluation and management documentation is HPI, and the elements are:

• Location

• Duration

• Severity

• Context

• Quality

• Modifying factors

• Timing

• Signs and symptoms

Let’s focus on severity.  Keep in mind that all of the HPI elements might not be documented in the history portion of the note. Information may be gleaned from throughout the chart for any element.

To satisfy the element of severity as part of the HPI for an E/M code, the condition does not have to be severe. The physician may indicate severity in various ways.

Severity could be shown using the familiar 1-10 pain scale, or documentation could use terms to describe the severity such as “very,” “tremendous,” “not too bad,” “not able to function,” etc. 

Severity could also be indicated when the provider indicates that the patient has not been able to perform an activity as a result of the illness or injury. Depending on the presenting problem, size could also be used to describe severity. Noting that a goiter is the size of a pea rather than the size of an orange certainly illustrates severity.

If the provider is documenting everything he or she learned by interviewing the patient, the severity element will be evident. Although ideally the note would be in the same format as the documentation guidelines, it does not have to be. Information satisfying the requirements could be found anywhere within the note.

Q: We have a Medicare patient who has asked about gender reassignment surgery. Is this something that Medicare covers? 

A: According to MLN Matters number MM9981 published April 4, 2017, the Centers for Medicare and Medicaid Services (CMS) reiterated its policy regarding gender dysphoria and gender reassignment surgery.  This reiteration was needed because a national coverage determination (NCD) was not created when CMS released the original information on August 30, 2016.  This was in response to public inquires requesting information about gender reassignment surgery among Medicare coverage information.

Medicare added information regarding gender reassignment surgery in the NCD Manual at Chapter 1, Part 2, Section 140.9.  The policy reads, “Effective for claims with dates of service on or after August 30, 2016, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.”

My suggestion is to contact your MAC and present this patient’s specific case in order for them to make a determination.  I would guess that this will be a lengthy process, regardless of where the patient is in their transition.