Wiki Pulling from HPI

[Greenpiper]

Can someone give me an idea of number of elements that can be pulled form this HPI.

New patient
Provider wants level 4 (99204)

Provider states 4.

Also, I have a coworker who states we can use Indication: colon cancer screening as a Location, Does anyone know if this is correct?

Chief Complaint:Colonoscopy consult

History of Present Illness:
57 Years Old Male who presents today for screening / diagnostic colonoscopy evaluation.
The patient was referred by: Ken
Indication(s): colon cancer screening
Current GI symptoms: diarrhea for 2-3 weeks after drinking lots of egg nog. no bloody stools or dark stools. no abd pain or vomiting.

I got
Location: no abd pain or vomiting
Duration: 2-3 weeks
Context: diarrhea for 2-3 weeks after drinking lots of egg nog.

Thank you

 

[Pathos]

Hello,

Whenever I audit a medical note in which the author does their own thing, I like to go back to basics and not overthink the guidelines too much.

CMS E/M guidelines explains:

"History of Present Illness (HPI)
HPI is a chronological description of the development of the patient’s present illness
from the first sign and/or symptom or from the previous encounter to the present. HPI
elements are:

* Location (example: left leg)
* Quality (example: aching, burning, radiating pain)
* Severity (example: 10 on a scale of 1 to 10)
* Duration (example: started 3 days ago)
* Timing (example: constant or comes and goes)
* Context (example: lifted large object at work)
* Modifying factors (example: better when heat is applied)
* Associated signs and symptoms (example: numbness in toes)

An extended HPI:
* 1995 documentation guidelines – Should describe four or more elements of the
present HPI or associated comorbidities
* 1997 documentation guidelines – Should describe at least four elements of the
present HPI or the status of at least three chronic or inactive conditions

For reporting services furnished on and after September 10, 2013, to Medicare, you may
use the 1997 documentation guidelines for an extended HPI along with other elements
from the 1995 documentation guidelines to document an E/M service."

I do not see enough HPI from the example given to qualify for an Extended HPI.

I would probably assign the HPI like so:

Chief Complaint: Diarrhea
Duration: 2-3 weeks
Context: After drinking lots of egg nog

Perhaps (and I say this since I was taught to not include "negatives" in the HPI):
-Quality: No bloody or dark stools
-Associated S/S: No abd pain or vomiting

Depending if your carrier accepts "negatives" in the HPI, the provider would get a Brief or Extended HPI.


Hope that is helpful.

 

[rystra@msn.com]

You could count the negatives toward your ROS (GI).

Could Neg vomiting be counted toward "constitutional"?