shellabell32
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Happy Friday!
I am trying to audit my Doctors for their hospital consults/admissions/visits. I have trouble sometimes identifying HPI elements and I am afraid I am leaving some on the table. For the following HPI I only see three elements. Wondering if there are any I am missing.
This is a 73 year old woman who presented with 3 days of abdominal pain and distention. She was having complaints of nausea and vomiting for a few days prior to admission. CT scan on admission shows demonstrated wall thickening and luminal narrowing of the sigmoid colon with proximal dilatation of the large bowel. The patient last had a colonoscopy in 2012 and seen to have diverticulosis although the scope could only be advanced to the sigmoid colon secondary to severe tortuosity and was thickening. The colon was biopsied at that point in time and seen to have only benign disease. The 3D colonoscopy in 2013 demonstrated thickening of the sigmoid colon with luminal narrowing as well.
This is all listed under the HPI though it seems a good part of it is history. They had the reason for consultation/CC listed separately as Large Bowel Obstruction
I appreciate any help, as I watch and read how to properly code E/M it makes perfect sense until I actually try to do it
I am trying to audit my Doctors for their hospital consults/admissions/visits. I have trouble sometimes identifying HPI elements and I am afraid I am leaving some on the table. For the following HPI I only see three elements. Wondering if there are any I am missing.
This is a 73 year old woman who presented with 3 days of abdominal pain and distention. She was having complaints of nausea and vomiting for a few days prior to admission. CT scan on admission shows demonstrated wall thickening and luminal narrowing of the sigmoid colon with proximal dilatation of the large bowel. The patient last had a colonoscopy in 2012 and seen to have diverticulosis although the scope could only be advanced to the sigmoid colon secondary to severe tortuosity and was thickening. The colon was biopsied at that point in time and seen to have only benign disease. The 3D colonoscopy in 2013 demonstrated thickening of the sigmoid colon with luminal narrowing as well.
This is all listed under the HPI though it seems a good part of it is history. They had the reason for consultation/CC listed separately as Large Bowel Obstruction
I appreciate any help, as I watch and read how to properly code E/M it makes perfect sense until I actually try to do it