Wiki Need to know HPI & ROS

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honeybindu

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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.
 
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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.
 
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honeybindu said:
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.
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