Wiki HPI definition

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tlwhlw

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Does anyone have a good definition for HPI??? I could use some help in explaining this to physician in my office. An example of what he used for HPI -- "81 y/o W Female here for F/U multiple problems"

I know this can't be right!!
Thanks,
Tracy, CPC
 
That is not even an acceptable chief complaint, much less an HPI.

I would get out the 95 and 97 guidelines for this.

HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient's present illness from
the first sign and/or symptom or from the previous encounter to the present. It includes the
following elements:
• location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.
Brief and extended HPIs are distinguished by the amount of detail needed to accurately
characterize the clinical problem(s).
A brief HPI consists of one to three elements of the HPI.
!DG: The medical record should describe one to three elements of the present
illness (HPI).
An extended HPI consists of four or more elements of the HPI.
!DG: The medical record should describe four or more elements of the present
illness (HPI), or the status of at least three chronic or inactive
conditions.

Laura, CPC, CPMA, CEMC
 
I'm writing specifically about dermatology. If a patient is seen for a full skin exam and their cc is for surveillance of lesions throughout the body and specifically about a new lesion on the chest, should every lesion that is examined be added to the hpi? One of my providers is insisting that it should. But if there is no history for that lesion, I disagree that it should be added to the hpi. Please advise.
 
lbiener said:
I'm writing specifically about dermatology. If a patient is seen for a full skin exam and their cc is for surveillance of lesions throughout the body and specifically about a new lesion on the chest, should every lesion that is examined be added to the hpi? One of my providers is insisting that it should. But if there is no history for that lesion, I disagree that it should be added to the hpi. Please advise.
Click to expand...

If there is 'no history for that lesion', then I'm not sure what they would be documenting for it.

But either way, it is really up to the provider to decide what information they do or do not feel is clinically significant and/or important to include in their documentation. As coders, we just assign the appropriate code based on what was documented - it's not within our scope to not tell them what they should or should not document, unless some kind of mistake or missing information makes it impossible to correctly assign a code.
 
lbiener said:
I'm writing specifically about dermatology. If a patient is seen for a full skin exam and their cc is for surveillance of lesions throughout the body and specifically about a new lesion on the chest, should every lesion that is examined be added to the hpi? One of my providers is insisting that it should. But if there is no history for that lesion, I disagree that it should be added to the hpi. Please advise.
Click to expand...

I'm curious what you mean by "no history of that lesion".
 
Since there are multiple lesions, each individual lesion does not need its own history. He can document the nature of the multiple lesions, average size, behavior, etc.

If a patient had acne, would he document each individual blackhead? No.
 
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