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HPI for cardiac consults

  1. #1
    Default HPI for cardiac consults
    Medical Coding Books

    I am auditing consultations done by a cardiologist. Patient was referred by her orthopedic surgeon.
    I am having trouble with some of the HPI. Here is an example:
    Patient is an 80-year old pleasant female with a longstanding history of hypertension. She complains of disabling pain in the left knee. It is also affecting her left hip joint. She also complains of generalized myalgia. She denies any chest pain, shortness of breath, palpitation or dizziness. She underwent left partial knee replacement about six years ago and is now schedule for a total replacement.
    I didn't want to use the "status of chronic conditions" because he didn't state the status. What elements of HPI can I count when it is hypertension? I can count Associated signs/symptoms for the pain and myalgia. What else?
    Thank you for your help

  2. #2
    Milwaukee WI
    Default Kind of a stretch
    Okay, this is kind of a stretch. The doctor is really covering two complaints here ... the hypertension (which is the reason for the consult, I presume), and the knee pain (which is why she's having surgery)

    Duration - "longstanding" and 6-years ago
    Assoc sign/sympt - pain, myalgia, no SOB
    Location - hip, knee, chest (negative, but location mentioned)
    Modifying factors - partial replacement

    Sure wish the doctor had mentioned what meds she's been on for the HTN.

    F Tessa Bartels, CPC, CEMC

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