Wiki HPI elements - auditing some claims

KoBee

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I have a question, I am auditing some claims and been noticing some coders have been using fever, shortness of breath, seizure as Location, do any of you guys agree with this as being acceptable??
 
HPI Elements

I'm relatively certain that they use these in the HPI because "FEVER" ties to the integumentary system while "SHORTNESS OF BREATH" ties to the respiratory system and "SEIZURE" ties to the nervous system.

If the HPI reads something like...Patient has had a fever for 3 days of 102 degrees. There is also dizzyness associated with the fever. Patient has been taking aspirin with only mild relief.

...you have your location, duration, associated signs and symptoms and modifying factors thereby satisfying the required 4 elements of the HPI.

Hope this is at least a little bit clearer...

Have a great weekend,

Joyce ;)
 
Not location

I would not count location for any of these statements. None of them answers the question "where is the problem?"

Oh, and Fever is constitutional, not integumentary.

F Tessa Bartels, CPC, CEMC
 
Hello, I agree with Tessa. The fever is Constitutional & none of the other statements you mentioned are considered as the location of the problem. So I would say none of those statements would be considered acceptable for the location of the problem.

Hope this helps!!!
 
Location

I do E and M coding and I have been advised that in HPI, fever would be constitutional, Shortness of Breath would be respiratory and Seizure would be neurological. Althought it does not specifically say the sstem, you know which system these symptoms refer to
 
Mea culpa - I wrote integumentary but meant to write constitutional. I do, however, stand by my comment that SOB is the respiratory and seizures are neurological.

Joyce
 
I'm pretty certain that "Location" should be the body area with the problem, not a body system.

I wouldn't say " I have pain in my neurological". ;)
 
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