HPI Location

cindygram

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This may be a dumb question but I am new to E & M coding...I was using the elements of location and duration in the HPI for our OB patients when the documentation read Pregnancy of 32 weeks...I was told this was not appropriate can someone elaborate for me. Thanks
 

grahamki

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I work in a Behavariol Medicine facility, and when I go over HPI elements with my physicians I tell them since our facility is for mental health that location (head) would NOT be a good reference to use unless they are coming in due to maybe cognitive deficits due to a TBI or CVA, or a recent head injury that is causing cognitive problems.

So I am taking it that your practice is an OB.GYN so I would agree that pregancy at how many weeks would not be good to use for duration and location.

As for documentation stating that you should not use those I don't know of any. But I would say that the situation would call for the type of practice you are in and coding for.
 
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