HPI Opinion

[khanninen]

I'm working up a fairly in depth review of our new EMR's auto-coding feature and would like some feedback on the following history. Something's a little off on the back end of this coding and I'm trying to get an idea of whether or not I'm just being too restrictive, if we have a data entry problem (i.e. scribing,) or if this is a programming problem.

CC: Excessive sun exposure, hair loss

Pt is here for a skin check. The patient is being monitored for excessive sun exposure.

Pt comes in for hair loss of scalp. Tried 5% Rogaine foam; did not like what it did to texture and scalp; hard to apply; now uses 2% nightly only. Hair loss is stable with no significant progression. No itching of scalp.
Thyroid: normal

Meds: lisinopril

PMHX: Double mastectomy for breast ca

FH: no significant hair loss/father bald at age 20/brother bald on top of head.

ROS: A focused review was performed and notable for good general health, up to date on GYN, upt to date on eye exam, no new skin lesions, no rash, no lumps and bumps, and no blood thinners.

Specifically, what would you count for HPI?

Thanks in advance for any and all opinions.

-Katie

[ollielooya]

Since any and all opinions are welcome, here is mine. Hopefully others will jump in to support or correct.
Location: scalp
Associated Signs and conditions; no itching of scalp
modifying factors : results of rogaine use

You need one more to reach the extended threshold, and I'm wondering about the statement "Hair loss is stable with no significant progression" Would this not count for severity. Just wondering.

Another thing I'm wondering about...Let's say the doctor had stated that patient is being monitored for excessive sun exposure and put in a timeline (perhaps the patient had been in a month ago, or six months ago, now wouldn't that give us another bullet to add and if so where?

Eager to see other's responses.
Suzanne E. Byrum CPC

[khanninen]

Suzanne,

Thanks for your response, it's much appreciated. After taking a deep dive with the scribe, I've uncovered where in the system my issue is, but now after talking with multiple MDs at my practice, I'm still stuck. The MDs are marking "excessive sun exposure" as context. Anyone have any thoughts on this?

Thanks,

Katie

[Evelyn Kim]

I would be inclined to agree with Suzanne about severity. Using excessive sun exposure is stretching the context a bit in my opinion. With out any further clarification about the excessive exposure such as how long or the reason for the need for monitoring this I would have a hard time counting it for context.

[khanninen]

Evelyn,

Thanks for your thoughts. A look through some of the paper charts from previous visits has shown me that many of these "excessive sun exposure" patients have experienced blistering sun burns as children, teens, or aduts, years of unprotected sun exposure. This theorectically places them at higher risk for developing skin cancer, hence their request for a skin exam. How to appropriately classify this in terms of where to "scribe it" in our EMR is now my next challenge. In the past, I simply classified this kind of statement (although not this specific wording but others that might fall into the same category,) as a problem statement and per my MACs guidelines, that was enough to qualify to a brief HPI. The issue is when the patient has a second chief complaint with 3 elements of HPI. When the excessive sun exposure is plugged into context (or anywhere else other than a free text box,) the dummy-coder does its dummy-count and now I have an extended HPI and a set-up for a possible up-code. Unless "excessive sun exposure" can really be used as a specific element of HPI. It's certainly a contributing factor...

-Katie

[MnTwins29]

Although I would agree with using severity for the hair loss, I get where the argument is about using it as context - there would be a greater risk to the scalp for sun exposure than if there was a "normal" head of hair - and I can understand that it can count as context, as this could also be countered with wearing a hat, etc. But I do agree with the others that it is better to count this under severity, where it seems clearer.

Opinion given - good question and scenario.