Help with HPI

JDM1228

Networker
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Montgomery, AL
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I am fairly new to E&M coding and could use some assistance on picking out the elements of the HPI for an initial inpatient encounter. .. I pulled out the pertinent info:

50 yr old reports to the ER with a 2 day history of "problems swallowing liquid and solids". The pt has no prior history of these complaints. The patient stated that yesterday while eating steak and potatoes, he got choked, coughed, and had problems swallowing since then. The patient also notes to have a weight loss of about 30-40 pounds over the past 3-4 months. The patient was status post EGD and was admitted for further evaluation. The EGD did not show any strictures. We did show some decrease in motility felt to be possibly secondary to Geodon.

So far I have duration, associated symptoms, and either context or timing... Any thoughts?
 
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4,456
Location
Milwaukee WI
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It's a stretch

Okay, I'm stretching some definitions here but ...

Duration - yesterday and since then
Context - eating
Severity - choked
Assoc S/S - cough
Quality - problems swallowing

Hoping you don't need any of that info for your ROS or PMFSH

F Tessa Bartels, CPC, CPC-E/M
 

RebeccaWoodward*

True Blue
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High Point, NC
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I am curious about something....would anyone count "esophagus" as a location?... "problems swallowing liquid and solids"..."status post EGD"... (possibly an inferred statement?) I can understand the concern for the side effects of Geodon.... Anyone else?
 

LLovett

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I would count location.

Duration- 2 days
Location- swallowing (esophagus)
Timing or Context- while eating
Modifying Factor- steak and potatoes
Severity- choked
Assoc Signs & Symptoms- coughed



Laura, CPC
 
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