HPI Elements-This new patient

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I have the following HPI scenario:

"This new patient to my practice presents today to establish me as his new primary care physician and to discuss a 2 week history of black stools. He also describes a 1 - 2 year history of progressive fatigue and shortness of breath. He denies any cough, wheezing, abdominal pain or pain with defecation. He last saw a doctor several years ago.
He voices no other complaints today."

I am having a discussion with colleagues about what the HPI elements are in this.
I would be interested in the opinion of other coders on this.

Thanks.
 

CatchTheWind

True Blue
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634
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Boca Raton, FL
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On the first complaint, I get duration (2 weeks), quality (black), and MAYBE location (stool, since the location is implied).

On the second complaint, I get duration (1-2 years), quality (progressive), and associated signs and symptoms (denies any cough, wheezing, abdominal pain or pain with defecation).

With the exception of Novitas (and possibly any commercial carriers), you cannot count the same type of element twice . So you have duration, quality, associated signs and symptoms, and possibly location.

I'd be interested in hearing from someone else whether an "implied" location can be counted (ie: does "shortness of breath" imply lungs, does sneezing imply nose, etc.)?
 

bedforak1

Guru
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Nashville, TN
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On the first complaint, I get duration (2 weeks), quality (black), and MAYBE location (stool, since the location is implied).

On the second complaint, I get duration (1-2 years), quality (progressive), and associated signs and symptoms (denies any cough, wheezing, abdominal pain or pain with defecation).

With the exception of Novitas (and possibly any commercial carriers), you cannot count the same type of element twice . So you have duration, quality, associated signs and symptoms, and possibly location.

I'd be interested in hearing from someone else whether an "implied" location can be counted (ie: does "shortness of breath" imply lungs, does sneezing imply nose, etc.)?
I would not give location for stool.
 
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