Wiki Elements for HPI

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Jody Mortensen

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Please read the HPI paragraph below & tell me how many elements you can count for the level & what level you get. I'm having a hard time with this due to multiple opinions on how many elements I get which to me qualifies for an expanded problem focused & another coder getting a detailed level for the HPI. The level has to meet a detailed for the EM level for observation & I don't believe it meets a detailed level.

Thank you
Jody

History of Present Illness: Shirley is an 82 year old woman who had been admitted to the hospital on 04/14 for back pain from a thoracic vertebral compression fracture. She was sent down to another hospital on 04/16 for a vertebroplasty she had done. On the way home she felt she had to go to the bathroom and stopped at the hospital here because her son was familiar with it. Here she felt tired & wanted to lay down & after laying down awhile her son decided he would rather have her spend the night here as he was uncomfortalbe taking her home due to her having pain. She was also feeling constipated. She was real sleepy after having the vertebroplasty.
 
Hpi

I'm a little confused, the highest level you can get for the HPI is extended (4 or more elements). I'm assuming you meant you need get a detailed history and therefore you need an extended HPI.

I keep getting a brief history. Is the chief complaint pain & being tired? In which case I think you could use "had to lay down" as a severity stmt. The context is "s/p surgery" but that's all I get.

maybe duraton of a few hours because we know the surgery was earlier that same day??

If you can't reach a detailed history, can't you drop the E/M to 99212 or 99213?

Lisi, CPC
 
I get ..

Quality: Pain
Assoc Sign : feeling constipated, tired
Duration: hard to tell, I think it's "today" but you have all these dates and I'm not sure of "today's" date
Context: after vertebroplasty (i.e. post surgical)

This is S T R E T C H I N G it a bit.

It would help if we knew what the chief complaint was .. The elements of the HPI should relate to the chief complaint.

F Tessa Bartels, CPC, CEMC
 
Further Information if Needed

To further explain: The chief compalint is pain & tired. The patient was admitted as an Observation patient, so I'm looking at CPT's 99218 & 99219. 99218 requires a detailed/comp hx & exam & a straightforward MDM. Upon my review for HPI & counting elements I can see location/duration & associated sign/symptoms which doesn't met a detailed history. The MD does meet a detailed ROS/detailed PFSH but needs to met detailed history in order to meet the history requirement for a 99218. He does meet the detailed exam & straightforward MDM. So I had another coder look at it & she came up the location/duration/signs symptoms & context which is 4 elements which according to a sheet put out by the State Medical Society of Wisconsin qualifies the HPI as detailed. I thought it would be good to get more opinions. If anyone could give me guidance I would appreciate any help, suggestions, advice.
Thank you
Jody
 
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