Wiki Counting HPI elements twice


Central Point, OR
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I have an HPI where the provider states that the rash has spread from her hand to her face and back of her left leg. Can I count each location as a point or do I only get 1 point for this?

Thanks for any help.
You get credit once. For documenting "location".

Think about it, if it were over the entire body, you wouldn't get credit for like 14 body areas.

You are counting the number of these elements, regardless of number of problems or locations.

Modifying Factors
Associated Signs and Symptoms
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Counting HPI elements more than once

We are looking for documentation (not an opinion) that we can give to our providers that states we can only count an element once for a problem.
For example - modifying factors, a patient is taking ibuprofen, using ice packs for pain. Would you count this as one modifying factor or two. Our provider wants to count this as two? We are looking an official guideline that states how to count HPI elements - one per problem.

Where can we find the official guideline to answer this?

Thank you for any help you can provide.
HPI elements

See the example of five HPI elements in the CMS Evaluation and Management Services Guide (bottom page 6) and note that "Symptoms somewhat relieved by warm compress and ibuprofen." counts as one element - modifying factors.

However, also check your specific payer's guidance as the same element might be counted twice for different problems presenting at the same visit.
Can a single HPI element be counted twice for the same encounter if it is related to two different complaints? Example: For “location” patient complaining of abdominal pain in the low right quadrant and left knee pain.

Answer: HPI elements can be counted as often as they apply to presenting complaints. Updated 6/9/2017 (Source: and management/em-faq_history)

I hope this is helpful.