Wiki Need to know HPI & ROS

[honeybindu]

Chief Complaints:
patient Complaint - workers comp accident on 12/13/2016, patient was hit and pushed on his Lt. side of abdomen with the front of forklift with a pallet. CT scan shows hernia.

HPI:
41 year old male, presents today for worker's comp follow up. Not feeling good. Too much pain , Lt subcostal area. Went to work today for 5 hours. 1 month post accident.

PMH, PSH & RX history.

Allergies - NKDA.

Billed code is 99214.

Kindly help me in finding HPI elements and ROS in the above scenario.

 

[thomas7331]

I would count this as 3 elements of HPI (location, duration and context) or 4 if you count 'too much' as severity. But there is no review of systems, so I'd consider it a problem-focused history. Some auditors count NKDA as a ROS point, in which case that would support calling this an expanded history. Either way, if it's to be coded as 99214, that means you'd need a detailed exam and moderate MDM.

 

[mhstrauss]

HUGE HIPAA violation up there, you need to get the patient's name off of that note before you post.

 

[alex.mckinley@aapc.com]

We edited the original post to exclude the private information shared. This is very concerning to us. Please ensure this does not happen in the future or we will be forced to dismiss you from AAPC forums. Thank you.

Chief Complaints:
patient Complaint - workers comp accident on 12/13/2016, patient was hit and pushed on his Lt. side of abdomen with the front of forklift with a pallet. CT scan shows hernia.

HPI:
41 year old male, presents today for worker's comp follow up. Not feeling good. Too much pain , Lt subcostal area. Went to work today for 5 hours. 1 month post accident.

PMH, PSH & RX history.

Allergies - NKDA.

Billed code is 99214.

Kindly help me in finding HPI elements and ROS in the above scenario.