Question HPI ELEMENTS

bharathiT

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cc: Patient come for multiple sites pain.
Assement : Knee,ankle,wrist,hand diagnosised as pain

Separate X-rays ordered for these four conditions.

HPI:
we have take 4 points (Knee,ankle,wrist,hand) based element (location).Bcoz all are have separate management so ?
 

Chelle-Lynn

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If I am understanding your question, you are asking if you are allowed "4" points for location under HPI as there are four sites notes; knee, wrist, ankle, hand. If this is the question then the answer is no. You would be allowed 1 point for location regardless of the separate management under HPI.

Another example would be Quality. If the provider documented words like itchy, sharp, greenish, etc. This would account for 1 point under quality and so on.
 

jimbo1231

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Agree with Chelle. Shouldn't be too difficult provider to document moderate pain in multiple locations since yesterday after tripping. You now have the 4 elements. Maybe you have a training issue Jim
 

RyanRaichCPC

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Local Chapter Officer
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I agree with both Jimbo and Chelle. Counting location four times is considered double dipping. How is the pain rated on a pain scale? How long has the pain been present? What are the modifying factors? Is the pain better with elevation, ice, rest? What is the quality of pain? Sharp, throbbing, constant, etc. Without seeing your entire HPI it is very hard to help determine your bullet points. If your physician isn't documenting any of this in his/her history then maybe sharing some education with your providers regarding what is needed for proper E/M documentation would be helpful and may increase your reimbursements.

CMS can be a good reference. For example this is from CMS:

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 (example: left leg)
Quality (example: aching, burning, radiating pain)
Severity (example: 10 on a scale of 1 to 10) Duration (example: started 3 days ago)
Timing (example: constant or comes and goes)
Context (example: lifted large object at work)
Modifying factors (example: better when heat is applied)
Associated signs and symptoms (example: numbness in toes)

All of the above can easily be documented in just a few sentences.
 

Chelle-Lynn

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No, each element can only be counted once for a 1 point. For example:

Patient was complained of pain in left shoulder for 3 days. She also stated that she has been sneezing for 7 days. Complains of Headache off and on.

Location = left shoulder, headache
Duration = 3 days, 7 days
Sym = Sneezing
Timing = Off and on

1 point for location
1 point for duration
1 point for sym
1 point for timing

Even though the duration reflects 2 conditions, it only accounts for 1 point. Even if you had 5 different duration references, it is only one point.
 
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