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Wiki Quality for HPI Element

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ch81059

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Hi,
I have a note with a patient presenting with a chief complaint of breast cancer. In the HPI it states that a biopsy revealed infiltrating ductal carcinoma. Could "infiltrating" be considered quality in the HPI?

Thanks!
 
Yes, but I would also like to recommend having your physicians bill by time on cases like these because breast lesions/cancers will always have relatively little to no HPI because it is usally discovered on mammography so there is no history to the patient (can't feel it, didn't know it was there, no time/quality/duration/context). But the patient will have a million questions for the doctor, and the doctor will spend a great deal of time coordinating care. So having said that... your physician should document his/her time and make notation that greater than 50% of that time was spent counseling and coordinating care with an outline of what was discussed/coordinated.

Holly Giffin, CPC
Physician Coding Auditor
 
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