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Wiki Hpi elements?

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veloso

Expert
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262
Location
Beechhurst, NY
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Hi All,
How many elements can I count for this particular encounter?
HPI:
42 year old female presents with c/o cracking dry skin of the heels x 2years. patient denies any trauma to the feet.
Thank you.
 
veloso said:
Hi All,
How many elements can I count for this particular encounter?
HPI:
42 year old female presents with c/o cracking dry skin of the heels x 2years. patient denies any trauma to the feet.
Thank you.
Click to expand...

I get:

location: heels
duration: 2 years
quality: cracking dry skin
associated signs and symptoms: denies any trauma to the feet

That is my take on it. Hope this helps
 
Hi Eadun,
I'm leaning towards billing this to 99203 but here is the progress note:(PODIATRY VISIT)
42 year old female presents with c/o cracking dry skin of the heels x 2years. patient denies any trauma to the feet.
Current Medication:
Medical History:
Borderline diabetes

Allergies/Intolerance:
N.K.D.A.

ROS:

Examination:
Vascular
PEDAL PULSES Dorsalis pedis, +1/4, bilateral, Posterior tibial, 0/4, bilateral. CAPILLARY REFILL TIME 2# of seconds x 10 toes. TEMPERATURE GRADIENT WNLs, bilaterally.

Dermatology
SKIN FINDINGS: Signs of:, fissure b/l heels and plantar forefoot b/l.

Assessment:
Chapping skin - 709.8 (Primary)

Plan:
Treatment:
Chapping skin
Start Lactinol Lotion, 10 %, Externally, 1 application to affected area, Twice a day

But I think I just code this to 99202 since I have only ONE ROS and how about my PHY.EXAM does it qualifies for level two following the 1995 DG.

I really appreciate the attention you gave in my thread.thanks a lot..God Bless..
 
I agree. 99202. Plus, I do not feel that the nature of the presenting problem would have warrented a 99203 anyway.

Have a great day!
 
Thanks... Everybody for the input this forum really helps me lot more power to all of us..in this unending struggle and learning career ...
 
I would not count the denies trauma to feet. In order to be able to count it as an associated sign/symptom it needs to be a positive. I could see counting this for ROS since you can use both positives and negatives.
 
Last edited:
stephegriffith said:
I would not count the denies trauma to feet. In order to be able to count it as an associated sign/symptom it needs to be a positive. I could see counting this for ROS since you can use both positives and negatives.
Click to expand...

Associated signs and symptoms do not need to be positive. How do you support that they are only "positives"?
 
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