"moderate in severity" as HPI element

CatchTheWind

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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

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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

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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

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What if it's an asymptomatic lesion? Can the patient's statement that it is asymptomatic be considered "mild" in severity?
 
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