How many HPI elements

rthames052006

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Good Morning:

I'm having a bit of a infarct this morning, I do believe I have atleast 4 HPI elements in this note but I just want to double check...

86 yr old female presents to the office today for a f/u of her UTI. She had a UTI, we had urine that had a little bit of klebsiella and it was sensitive to just about everything except Amoxicillin. It was indeterminate with Macrobid, but Macrobid concentrates in teh urine. She was asymptomatic. We're going to repeat another UA dipstick just to make sure we wiped it out. She is asymptomatic as far as symptoms now. Otherwise, no SOB, no CP, she feels good, looks good. Blood sugars have been doing well. Renal functions were up just a little bit but there is no protein in the urine. We're going to follow up on this as well as the blood count in the next month and then see her back as scheduled.

I have location= GU
quality= she feels good
modifying factors= amoxicillin
assoc signs and symptoms= no SOB


I hear from time to time that what I am using as quality ( she feels good) is iffy?

Any takers?

TIA
 
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LLovett

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I wouldn't count that as quality personally.

If I had to try and pull a 4th element I would be tempted to go context with the UA. Although I don't really like that either.

Curious if it even matters. Wouldn't think you would have much of an exam for this visit and if there is only 1 established problem and even if it is worsening you will be stuck at Low MDM. Looks like a 99213 to me.

Just my take on it,

Laura, CPC, CPMA, CEMC
 

rthames052006

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I wouldn't count that as quality personally.

If I had to try and pull a 4th element I would be tempted to go context with the UA. Although I don't really like that either.

Curious if it even matters. Wouldn't think you would have much of an exam for this visit and if there is only 1 established problem and even if it is worsening you will be stuck at Low MDM. Looks like a 99213 to me.

Just my take on it,

Laura, CPC, CPMA, CEMC
Thank you Laura, I appreciate your take on this. The patient does have a few underlying chronic conditions (DM, Hx of HTN, hyperlipidemia and DJD) that the provider does not give the status of or address in the note except for the diabetes. He does have 8 or more organ systems that he examined by 1995 DG's. When I calculate the overall MDM I come up with low, as you did, even with the status of the diabetes. But I'm getting some flack over the downcoding from a 99214 to 99213.

I just wanted to get another opinion and was on the fence about actually allowing the statement of "she feels good" as quality.

Thanks much :)
 
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"feels good" is not quality

I agree that I would not use "she feels good" as quality.

I also would not use "amoxicillin" as modifying factor. There is no evidence here that they gave her amoxicillin or any other drug to treat the UTI. In fact it states that the report was sensitive to everything except amoxicillin.

I might count "little bit of klebsiella" and the later statement about "no protein" to signify quality or perhaps severity ... i.e. what kind of infection, or how bad it was.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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