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HPI Descriptors-definitions

  1. Question HPI Descriptors-definitions
    Medical Coding Books
    I'd like to know if there's any documentation as to what each discriptor means and examples. Obvious is location, duration, severity, mod fact and as&s. We are disagreeing on the quality, timing and context. I have a "cheat sheet" I've been using for years but cant remember where I got it. Since it's a provider who is disagreeing with me I need the hard proof! Any ideas or web links you can offer would be great! Thanks.

  2. #2
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    HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

    Location. For example, pain in left leg;

    Quality. For example, aching, burning, radiating;

    Severity. For example, 10 on a scale of 1 to 10;

    Duration. For example, it started three days ago;

    Timing. For example, it is constant or it comes and goes;

    Context. For example, lifted large object at work;

    Modifying factors. For example, it is better when heat is applied; and

    Associated signs and symptoms. For example, numbness.

    This is from cms, here is the link

    http://www.cms.hhs.gov/MLNProducts/d...serv_guide.pdf


    Laura, CPC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Hpi
    Here's what I picked up from a recent seminar:
    The 8 elements in the HPI are as follows:
    LOCATION - where - the site, diffuse or localized
    QUALITY - what kind - sharp, dull, constant, intermittent, improved/worsening
    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 - continuous or repetitive
    CONTEXT - what brings it on - does it occur with a specific activity
    MODIFYING FACTORS - what makes it better or worse - prior treatment or medication tried
    ASSOC SIGNS & SYMPTOMS - what comes with it - symptoms that accompany the main complaint - could be negative (no pain, or no fever)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    Tessa ~

    Thank you. That was what I was looking for. What seminar was it?

    I'm also still wanting to know if there is a web site (besides CMS) that expands on the descriptors. Kelly Sanders, CPC

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Medical Society of Wisconsin, Sept 2008
    The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

    Glad I could help.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Default
    Quote Originally Posted by FTessaBartels View Post
    The Medical Society of Wisconsin holds a Coding Symposium each fall. The info on the HPI was on a handout from one of the sessions (about how to educate your physicians on proper documentation).

    Glad I could help.

    F Tessa Bartels, CPC, CEMC
    Thanks for that info Tessa... I had a huge notebook full of notes for HPI and ROS and I just recently lost it...

    I'm starting a new one with the wonderful info you just gave.

    Thanks much!
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  7. #7
    Location
    North Carolina
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    3,126
    Default
    A seminar that I attended had these examples

    Quality:Any charateristic about the problem or how it feels or looks- "green" phlegm, "popping" elbow, "dull" ache, "sharp" pain, "metallic" taste

    Timing:"intermittent", "constant", lasted "10 minutes", "occasional", "off and on"

    Context:What the pt was doing/enviromental factors, etc.-"while sleeping", "slipped and fell", "when arguing with husband"

    http://www.physiciansnews.com/business/708andress.html

    Maybe this link will be helpful~

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