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Help with HPI

  1. #1
    Default Help with HPI
    Medical Coding Books
    I am fairly new to E&M coding and could use some assistance on picking out the elements of the HPI for an initial inpatient encounter. .. I pulled out the pertinent info:

    50 yr old reports to the ER with a 2 day history of "problems swallowing liquid and solids". The pt has no prior history of these complaints. The patient stated that yesterday while eating steak and potatoes, he got choked, coughed, and had problems swallowing since then. The patient also notes to have a weight loss of about 30-40 pounds over the past 3-4 months. The patient was status post EGD and was admitted for further evaluation. The EGD did not show any strictures. We did show some decrease in motility felt to be possibly secondary to Geodon.

    So far I have duration, associated symptoms, and either context or timing... Any thoughts?

  2. #2
    Milwaukee WI
    Default It's a stretch
    Okay, I'm stretching some definitions here but ...

    Duration - yesterday and since then
    Context - eating
    Severity - choked
    Assoc S/S - cough
    Quality - problems swallowing

    Hoping you don't need any of that info for your ROS or PMFSH

    F Tessa Bartels, CPC, CPC-E/M

  3. #3
    I definitely wouldn't have thought to use some of those under the elements listed. Thanks so much for your response!!

  4. #4
    North Carolina
    I am curious about something....would anyone count "esophagus" as a location?... "problems swallowing liquid and solids"..."status post EGD"... (possibly an inferred statement?) I can understand the concern for the side effects of Geodon.... Anyone else?
    Rebecca CPC, CPMA, CEMC

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  5. #5
    I would count location.

    Duration- 2 days
    Location- swallowing (esophagus)
    Timing or Context- while eating
    Modifying Factor- steak and potatoes
    Severity- choked
    Assoc Signs & Symptoms- coughed

    Laura, CPC

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