stethoscope

Posted and filed under Coding, Healthcare.

Severity is a statement or a rating of intensity (0-10) from the patient that indicates the degree or measurement of how bad the chief complaint is. This rating not only is documented based on 0-10 scale, but it can be captured using phrases such as: worsening, improving, and increasing.

An auditor performing a medical necessity review is able to use the severity of the problem in combination with the treatment plan to help determine if the claim was medically necessary.

Example 1: Mr. Smith returns to the office today stating the swelling and pain in his left arm is improving. Improving should be credited as the HPI-Severity element.

Example 2: Josephine Johnson presents to the walk-in clinic. Stating she tripped while carrying groceries into her home. She landed on her arm and her right side is bruised. She states her arm hurts; the pain is an 8. Pain on the scale of 8 should be credited as the HPI-Severity element.