• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

"moderate in severity" as HPI element

CatchTheWind

True Blue
Messages
590
Best answers
0
Can you count this statement (describing a skin lesion) toward the severity level in HPI? "It is moderate in severity." Or does the provider need to be more specific, like stating the size of the lesion, the pain (if any) it is causing, etc. (And if so, how do I know from a statement of the size of the lesion how severe this size is considered?)
 

Orthocoderpgu

True Blue
Local Chapter Officer
Messages
853
Location
Salt Lake North
Best answers
0
Techncally yes but...

I love skin lesions and the physicians who pick out their HPI elements in the EHR. My favorite is "The symptoms occur constantly". Well it's a skin lesion. It's not going anywhere. So the computer is going to give credit for meeting a meaningless HPI element.

Technically I think you could use it, but how is it "Moderate". What makes it "Moderate" versus something else?

I once had a physician put N/A in four different HPI elements and of course the wonderful computer counted all four elements and spit out a meaningless code. That's where you come in.

The HPI elements were designed to get information that was "Medically Necessary" about the patient's medical condition. That is now lost due to EMR's.
 

ellzeycoding

Guest
Messages
392
Best answers
0
According to the AAPCs E/M training module

Severity: A degree of measurement of how bad it is (eg, improved, unbearable pain, 8 on a scale of 1 to 10, etc.)

I would say moderate can be used as HPI depending on the context of what's being described or the condition itself.

For example...

If it's a painful, bleeding lesion, and the patient describes it as "moderate", I'd say it counts.

If it's inflamed, and it's moderately inflamed, I'd say it counts

IF its a rash, and it's moderate in severity, I'd say it counts.
 

CatchTheWind

True Blue
Messages
590
Best answers
0
What if it's an asymptomatic lesion? Can the patient's statement that it is asymptomatic be considered "mild" in severity?
 
Top