• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

Tools for documenting HPI

dclark7

True Blue
Messages
723
Location
Hartford, CT
Best answers
0
Hi everyone,
My docs are looking for some type of tool they can use to help them remember what they need to document for HPI. We have medicare's E/M Documentation Auditors' Instructions, but this doesn't really help them. I figured rather than reinventing the wheel I'd see if anyone has something they use. Thanks.

Doreen, CPC
 

dclark7

True Blue
Messages
723
Location
Hartford, CT
Best answers
0
Thanks, at least I have someplace to start. I don't know why they have such a problem with the HPI, but this seems to be their weakest area of documentation.

Doreen
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
Hpi

History of Present Illness has 8 elements, as follows:

Location - "where" - site, diffuse or localized
Quality - "what kind" - sharp, dull, constant, intermittent, improved, worse
Severity - "how bad is it" - pain scale 1-10, mild or severe
Duration - "how long" - length of time it has been present
Timing - "Is there a pattern" - relation ot something else, continuous or repetitive
Context - "what brings it on" - does it occur with a specific activity?
Modifying factors - "what makes it better or worse" - prior treatments or medications tried, worse w/ exercise, better with heat
Assoc Signs & Symptoms - "what comes with it" - symptoms that accompany the main symptom.

F Tessa Bartels, CPC, CPC-E/M
 

dclark7

True Blue
Messages
723
Location
Hartford, CT
Best answers
0
Thansk, Wendy, I replied to your message. As for the 8 elements, I have explained in every way I can think of what needs to be document. The doc I work for seem to do better with visual aids.

Doreen, CPC
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
Examples help

Doreen,
Maybe an example will help:

Patient fell off swing yesterday, and noted immediate sharp pain in left wrist. This morning wrist is noticeably swollen and bruised.
Here you have 4 elements of HPI -
Duration - yesterday
Quality - sharp
Location - left wrist
Assoc sign - swollen, bruised

OR ...

Patient with intermittent chest pain for past two days, described as "mild, more like tightness," worse with exercise such as going up stairs
This gives up 5 HPI elements (you only need 4 for highest level)
Timing - intermittent
Location - chest
Duration - two days
Quality - mild
Context - worse w/ exercise


Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example).

Good luck!

F Tessa Bartels, CPC, CPC-E/M
 
Top