Deciding HPI

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Garnet Valley, PA
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Hi,
I have a confusion. I am doing practicode, where in one case HPI is decided on associated sign and symptom (NO LOSS OF CONSCIOUSNESS OR SEIZURE). I thought if there is presence of any associated sign and symptom then only we can consider it. Am I right? Please clarify. Thanks.
 

amyjph

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Munising, MI
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amyjph

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Munising, MI
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This is one of those grey areas in coding and if you asked 5 auditors you would probably get 5 answers. In my opinion the absence of/negative response to this can sometimes be counted if related to the presenting problem. The provider can use this in the overall picture of the visit. Using your example above. Say the patient presented for a head injury. Knowing there was no loss of consciousness or a seizure would be related to the presenting problem and informs the provider even though negative. It can impact what is done in the exam or MDM. "Usually" there are enough HPI elements that you wouldn't get too hung up on this one anyway.

Does the rationale area in Practicode explain it (kind of like when you take a practice exam and get one wrong)?

This explains well: https://www.medicaleconomics.com/view/understand-role-associated-signs-and-symptoms

CPT defines HPI: HPI is a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem.

I see it almost like saying the severity is 0/10 pain for example. They get credit for the element even if there is no pain.
 
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