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coder25

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Hello,

How would you code the following HPI. I can only find 3 items, can anyone else find one more for a complete HPI?


The patient is a 34-year-old female seen at the request of Dr. ..... The patient is 5'0" tall, weighs 246 pounds with a BMI of 48.1. She has failed multiple medical attempts at weight loss. She hsa no specific complaints today in the office and is here to discuss laparoscopy Roux-En-Y gastric bypass. She completed a preoperative variatric program per her insurance company. I reviewed her past medical, surgical, family, and social history as noted on her intake sheet, in the office today.

This is what I get:

Problem: Obesity
Quality: Morbid
Modifying: Preoperative bariatric program.

Anything else?

Thanks.
 
HPI elements.....

coder25 said:
Hello,

How would you code the following HPI. I can only find 3 items, can anyone else find one more for a complete HPI?


The patient is a 34-year-old female seen at the request of Dr. ..... The patient is 5'0" tall, weighs 246 pounds with a BMI of 48.1. She has failed multiple medical attempts at weight loss. She hsa no specific complaints today in the office and is here to discuss laparoscopy Roux-En-Y gastric bypass. She completed a preoperative variatric program per her insurance company. I reviewed her past medical, surgical, family, and social history as noted on her intake sheet, in the office today.

This is what I get:

Problem: Obesity
Quality: Morbid
Modifying: Preoperative bariatric program.

Anything else?

Thanks.
Click to expand...

Hi,

I suggest that "no pecific complaints" may be cosidered as Associate signs and symptoms since the physician has enquired about the reason for visit
which would not be associated the Pre Operative programme..

herman
 
Sorry, no

Sorry, but I wouldn't give credit for "no other complaints" as associated signs. If the physician had documented something like "no joint pain" I'd count THAT as associated signs.

And "problem" isn't one of the elements of HPI - location, timing, duration, modifying factors, quality, severity, associated signs, context.

I'll give you severity as the height/weight and BMI are listed. And I would count modifying factors ("failed multiple medical attempts at weight loss" and "completed the preoperative... program")

In my estimation there's no way to get to a complete HPI from this documentation.

F Tessa Bartels, CPC, CEMC
 
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