Hpi

MARY K

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I'll start out by stating I work for some Doctors set in there way. These Doctors like to use pain w/o any descriptors as a bullet. Should pain alone be counted? Any advice would be appreciated. thanks for help
 

MnTwins29

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I wouldn't use it

Not unless you have something else such as location, severity, context, modifying factors, etc. Can you at least get a location of the pain out of them, at least something general like "it hurts all over"?
 
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Question is too vague

I'm sorry but I don't really understand your question.
Perhaps posting a sample History to illustrate your question would help us give you an answer.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

MARY K

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Here is example of History giving:
This is a 33 year old female who is seen with a history of dropping a tool box on the dorsum of her left hand. She complanins of pain over the second and third metacarpals dorsally. No change in her neurological status of the hand is noted.

This is just an example of HPI, I know I have location and context, but being this is a new problem for an established patient I would like to count pain. This Dr believes pain should get him a bullet. Please any thoughts out there. Thank you
 

aaron.lucas

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you should probably show the Dr the list of applicable HPI items in the E/M guidelines. pain itself isnt in the list, and therefore wouldn't get it's own bullet. or you could explain it as pain is included in the two bullets you have (location of pain, context of pain, etc.) does this help? :)
 

LindaEV

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you should probably show the Dr the list of applicable HPI items in the E/M guidelines. pain itself isnt in the list, and therefore wouldn't get it's own bullet. or you could explain it as pain is included in the two bullets you have (location of pain, context of pain, etc.) does this help? :)
Agree. pain seemd like the CC here. would just need one word...severe...pulsating...etc.
 

MnTwins29

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modifying factors

Another thought could be if he explained the lack of neuro changes, such as no change even after starting ________ (fill in current med here). Or if the pt was taking OTC's such as Tylenol, aspirin, etc. Many possibilities for making pain count.
 
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Needs more to count

In your example, "pain" by itself counts for nothing, as it is your chief complaint.

You have context (dropped toolbox); location (left hand); and associated signed (no neuro changes)

If he included WHEN the injury happened, you would also have duration.
If he stated HOW BAD the pain is (3-5 out of 10), you would have severity
If he stated what the patient has done (used ice packs, took OTC Tylenol), you would have modifying factors
If he qualified the pain (pulsating, stabbing, burning), you'd have quality

Hope that helps you help him.

F Tessa Bartels, CPC, CEMC
 
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