HPI information

shruthi

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In an E&M record, if the HPI part states -- patient is a poor historian with only 2 HPI elements. Can we consider this as Extended HPI?
Also if the HPI part states -- patient is currently intubated, therefore the history was obtained from the chart. Then can we consider this as Extended HPI?

Kindly advice. Any document related to this would be very helpful.

Thanks.
 

jdibble

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If the patient is incapable of providing the History portion of the visit, as long as it is well documented the reason why and what measures were taken to obtain the information, you can get credit for a comprehensive history. Stating only that a patient is a poor historian I would think the provider would need to elaborate further - i.e. patient has dementia, to establish the reason. I know our MAC, Novitas, allows this documentation. You may want to double check with your MAC to see if they have different requirements.

Hope this helps!
 

EChombor

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Hpi

But what if the hpi had two elements.it is a problem focused or extended since both need 1-3 elements how do u know which to use
 

shruthi

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If the patient is incapable of providing the History portion of the visit, as long as it is well documented the reason why and what measures were taken to obtain the information, you can get credit for a comprehensive history. Stating only that a patient is a poor historian I would think the provider would need to elaborate further - i.e. patient has dementia, to establish the reason. I know our MAC, Novitas, allows this documentation. You may want to double check with your MAC to see if they have different requirements.

Hope this helps!
Thank you Jodi Dibble.

Hope the same point is applicable if the document states -- patient is currently intubated, therefore the history was obtained from the chart.
 
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jdibble

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Thank you Jodi Dibble.

Hope the same point is applicable if the document states -- patient is currently intubated, therefore the history was obtained from the chart.
I think that would be sufficient - it is saying why the patient cannot give history and states where the information came from. I would count it as a comprehensive history!
 

jdibble

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But what if the hpi had two elements.it is a problem focused or extended since both need 1-3 elements how do u know which to use
The HPI is one component of the History. You need to determine the level of the ROS and the PFSH first - then put the three together to see if it is Problem focused or Extended - i.e if you have no ROS or PFSH, then it would be problem focused; if you have at least 1 ROS and no PFSH, then it would be Expanded. Also keep in mind that if you only have 1-3 elements of an HPI and have an Extended or Complete ROS and PFSH, you would still only be able to qualify the History as expanded as all three components must meet or exceed the lowest level.

Now, in regards to the question asked on this thread, if a patient is not able to give this information due to their condition - unconscious, dementia, intubated for example, you can get credit for a comprehensive history if the provider documents the reasons why they could not obtain the information and show what measures they took to try and obtain this information.

Hope this answers your question!
 
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