HPI Components

pglazener

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I'm looking for some help as I am having a conversation with one of the doctors I work with. Here is what is documented in the chart for HPI.

Patient presents with mixed hyperlipidemia. Most recent lab tests include total cholesterol level ( 179 mg/dl ), triglycerides ( 265 mg/dl ), HDL ( 37 mg/dL ), LDL cholesterol ( 85 mg/dl ), small ldl 1553, hdl-p 27.9, and ldl-p 2350. had pap and they obtained labs, was told to see pcp for possible meds

This is a new patient and therefore requires at least 4 components for new illnesses. I would appreciate any opinions given.
 

mac

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minimum requirement is of Brief HPI for a new patient code 99201. For Brief HPI we only need 1-3 HPI of elements. For Extended HPI you require at least 4 HPI elements.
Thanks
 

Pam Brooks

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I'm looking for some help as I am having a conversation with one of the doctors I work with. Here is what is documented in the chart for HPI.

Patient presents with mixed hyperlipidemia. Most recent lab tests include total cholesterol level ( 179 mg/dl ), triglycerides ( 265 mg/dl ), HDL ( 37 mg/dL ), LDL cholesterol ( 85 mg/dl ), small ldl 1553, hdl-p 27.9, and ldl-p 2350. had pap and they obtained labs, was told to see pcp for possible meds

This is a new patient and therefore requires at least 4 components for new illnesses. I would appreciate any opinions given.
Patient presents with mixed hyperlipidemia. You have a chief complaint.

Most recent lab tests include total cholesterol level ( 179 mg/dl ), triglycerides ( 265 mg/dl ), HDL ( 37 mg/dL ), LDL cholesterol ( 85 mg/dl ), small ldl 1553, hdl-p 27.9, and ldl-p 2350. Although documented in the subjective portion of the note, I'd reserve this information for your MDM/data. These are lab results. You might be able to get "timing" out of "most recent".

had pap and they obtained labs, was told to see pcp for possible meds. Good information...not clear if it's related to the chief complaint, though. If I was feeling generous, I might credit the 'obtained labs' as modifying factors, but you'd have to catch me on a really good day.

Overall, this is a brief History, I don't see any system review, or PFSH, so couldn't comment on whether or not you would be able to do better than just the single HPI element.

Show your physician the eight history elements, and explain to him that he needs to be able to tell you the story of this patient's condition and associated co-morbidities or unrelated problems. This is a new patient.....is there more that's going on? Sometimes it's helpful to find out what they typically ask the patient, and then help them translate that into a concise note. I tell my providers...."your documentation has to explain to me what went on in the exam room, I can't be inside your head"!!

Good luck!
 

mls101163

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I would choose "was told to see pcp for meds" as your chief complaint.....you have location and you may have Quality by reference of "mixed" hyperlipidemia......which describes the type of hyperlipidemia....but as always, it depends on the auditor.......keep in mind the History portion is subjective.......the patient or guardian is telling you what is going on.....I'm almost positive the patient would not be telling you the lab values of all that was ordered. If it doesn't sound like the information is coming from the patient/guardian I wouldn't include it in my assessment.

Mary Lou Saunders, CPC
Upstate NY
 
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Why E/M is so interesting

This is a good example of why E/M coding is so interesting - and frustrating.

Chief Complaint: hyperlipidemia

HPI elements: QUALITY (mixed), SEVERITY (lab values quantify how bad it is), CONTEXT (they obtained labs and told pt to see PCP)

QUESTION - do you have any other history? PFSH? ROS?
If the answer is NO ... then you MIGHT be able to count "had pap" as ROS for OB/GYN and still qualify as an EPF history ... but that's is a MIGHTY LONG stretch.

Depending on exam and MDM you'll have either a 99201 or 99202 (at best).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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