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  1. #1
    Default hpi
    Medical Coding Books
    What Level Of Hpi Does One Get Out Of This.

    She Is A 54-year Old Female Recently Found To Have A Left Breast Cyst After An Abnormal Mammogram. This Was Aspirated Recently With Resolution Of The Cyst. She Is Her For Follow-up. She Did Not Find This Herself. It Was Completely Asymptomatic.

    She Also Complains Of Feeling Her Heart Pound In Her Neck, Particularly At Night When She Sometimes Awakens From Sleep. She Is On A Combination Of Toprol-xl And Hyzaar For Hypertension. She Doesn't Have Any Blood Pressure Measurements Iwth Her Of Recent.

    The Two Ros Are Met. Not Noted Here.

    Daniel, Cpc

  2. #2
    I say it is detailed.

    Modifying factor-aspirated or this could be used as past history if no other was obtained

    Severity-awakens from sleep
    Modifying factors- medications she is on

    Laura, CPC

  3. #3
    Here is what I find:
    CC: Cyst
    Location: Breast
    Severity: Asymptomatic
    Modifying Factor: Resolved by aspiration.

    CC: Heart pounding sensation
    Location: Neck
    Timing: particularly at night when she wakes up.

    For modifying factor credit, it should state if something is making it better or worse, so I wouldn't count the meds here. So for both complaints, I only come up with a brief HPI.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    National Advisory Board Member 2018-2021, Region 6 Great Lakes

  4. #4
    Milwaukee WI
    Default Detailed
    I come up with detailed (but I assumed that chief complaint is separately recorded, just as ROS is)

    Duration - recently
    Location - breast
    Quality - cyst
    Context - after mammogram
    Modifying factors - aspirated w/ resolution
    Assoc sign/sympt - asymptomatic

    I didn't even count the heart pounding paragraph because I already had 4+

    F Tessa Bartels, CPC, CPC-E/M

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