• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki HPI Descriptors-definitions

Create Wiki
C

codingwithkelly

Contributor
Messages
15
Location
Gresham, OR
Best answers
0
I'd like to know if there's any documentation as to what each discriptor means and examples. Obvious is location, duration, severity, mod fact and as&s. We are disagreeing on the quality, timing and context. I have a "cheat sheet" I've been using for years but cant remember where I got it. Since it's a provider who is disagreeing with me I need the hard proof! Any ideas or web links you can offer would be great! Thanks. :cool:
 
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. HPI elements are:
•
Location. For example, pain in left leg;
•
Quality. For example, aching, burning, radiating;
•
Severity. For example, 10 on a scale of 1 to 10;
•
Duration. For example, it started three days ago;
•
Timing. For example, it is constant or it comes and goes;
•
Context. For example, lifted large object at work;
•
Modifying factors. For example, it is better when heat is applied; and
•
Associated signs and symptoms. For example, numbness.

This is from cms, here is the link

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


Laura, CPC
 
Hpi

Here's what I picked up from a recent seminar:
The 8 elements in the HPI are as follows:
LOCATION - where - the site, diffuse or localized
QUALITY - what kind - sharp, dull, constant, intermittent, improved/worsening
SEVERITY - how bad is it - pain scale 1-10, mild or severe
DURATION - how long - length of time it has been present
TIMING - is there a pattern - continuous or repetitive
CONTEXT - what brings it on - does it occur with a specific activity
MODIFYING FACTORS - what makes it better or worse - prior treatment or medication tried
ASSOC SIGNS & SYMPTOMS - what comes with it - symptoms that accompany the main complaint - could be negative (no pain, or no fever)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Tessa ~

Thank you. That was what I was looking for. What seminar was it?

I'm also still wanting to know if there is a web site (besides CMS) that expands on the descriptors. Kelly Sanders, CPC
 
Medical Society of Wisconsin, Sept 2008

The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

Glad I could help.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

Glad I could help.

F Tessa Bartels, CPC, CEMC
Click to expand...

Thanks for that info Tessa... I had a huge notebook full of notes for HPI and ROS and I just recently lost it...

I'm starting a new one with the wonderful info you just gave.

Thanks much!
 
A seminar that I attended had these examples

Quality:Any charateristic about the problem or how it feels or looks- "green" phlegm, "popping" elbow, "dull" ache, "sharp" pain, "metallic" taste

Timing:"intermittent", "constant", lasted "10 minutes", "occasional", "off and on"

Context:What the pt was doing/enviromental factors, etc.-"while sleeping", "slipped and fell", "when arguing with husband"

http://www.physiciansnews.com/business/708andress.html

Maybe this link will be helpful~
 
You must log in or register to reply here.
Top