ED Coding and Reimbursement Alert

Question: Can you give me the total number of elements in the HPI example that follows:

70 year-old white male with history of renal colic and abdomen fistula presents with flank (location) pain consistent with prior episodes of renal colic. Patient is a 70 year-old male presenting with kidney stones. Pertinent negatives no chills (associated signs and symptoms), urinary frequency, hematuria, nausea, urgency or vomiting. His past medical history is significant for kidney stones.

Nebraska Subscriber

Answer: There are two clear HPI elements for location and associated signs and symptoms. You could make an argument for adding severity as implied by the statement "consistent with prior episodes of renal colic", which would yield three elements. If the provider had stated when the pain started or how bad it was, then it would have been easy to get to a extended HPI using location, duration, severity, associated signs and symptoms. Unfortunately, the provider did not mention the onset. This would not make the grade for an extended HPI.