HPI elements when pt is asymptomatic??

mgord

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I work for a General/Vascular Surgery practice. Two of the surgeons are questioning how they can meet the required elements for HPI when the pt has an asymptomatic breast lesion or carotids, or when a cancer pt comes in for consult to have a port placed for chemo.
Does anyone have any tips I could give them to meet the number of elements required to bill anything higher than a level 2? Or could direct me to a resource that can help me educate them as to what they should be including in their dictation to meet the elements??
Thanks!
 

pamtienter

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OK, I'm not a surgery coder but will give this one a try. Anyone can feel free to correct me.

For the breast lesion:
CC: lesion
Location: breast
Severity: asymptomatic
Right there are 2 elements of HPI. Is there a duration of how long they've had it? There is another element. Are there any associated signs or symptoms? Possibly another credit for "no breast pain" as a negative to the associated sign or symptom.

For the port placement, can you use the cancer as the chief complaint, since it is the reason for the port? Then you would have the location, duration, severity, etc. If not, what do you use?
 

RebeccaWoodward*

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I agree with Pam...nice example. When I meet with my providers, this question often comes up. Pam's tips are some that I suggest and for those patient's that have no complaints but come in for...lets say "refills"...many have chronic conditions. Example...DM, HTN, Hyperlipidemia, etc. For those patients, I suggest that the provider expand on the 3 chronic conditions and address their status'. Have you seen Dr. Jensen's website? It's packed with information. I, personally, think he's one of a kind for providing something to the coding world without strings attached.

http://emuniversity.com/HistoryofPresentIllness.html
 
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The 8 elements of HPI

I attended a conference earlier this year where one presenter, who is an MD, spoke about her efforts to educate the doctors in her practice. (She had become known as the "coding queen" in her office.) For HPI, she tried to form a question for each element that the physicians would understand:

Location - Where is it? - the site, diffuse, localized
Quality - What kind? - sharp, dull, improved, worsening
Severity - How Bad Is it? - pain scale 1-10, mile or severe
Duration - How long? - length of time it's been present
Timing - Is there a pattern? - relation to something else, continuous, repetitive
Context - What brings it on? - occurs with a specific activity
Modifying Factors - What makes it better or worse? - prior treatment or medication tried
Assoc Sign & Syjmptoms - What comes with it? - symptoms that accompany the main complaint.

So for your example of breast lesion
Quality - lesion
Location - breast
Assoc Sign/Sympt - asymptomatic

If your physician included one more element - when was it noticed (duration), what size is the lesion (severity) - you'd have 4 elements for the highest level HPI.

This week's "Case of the week" on emuniversity.com is an HPI that is just 3 or 4 lines long ... Use it to help educate your docs.

F Tessa Bartels, CPC, CPC-E/M
 
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