Results 1 to 7 of 7

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
    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

    Laura, CPC

  3. #3
    Milwaukee WI
    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
    Milwaukee WI
    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
    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

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

  7. #7
    North Carolina
    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"

    Maybe this link will be helpful~

Similar Threads

  1. Work descriptors
    By losborn in forum Dermatology
    Replies: 4
    Last Post: 06-23-2015, 11:27 AM
  2. HPI/ROS descriptors/definition
    By andersont in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 03-22-2013, 10:19 AM
  3. I&D Definitions
    By btadlock1 in forum Dermatology
    Replies: 7
    Last Post: 11-06-2011, 09:57 AM
  4. E and M definitions
    By rex.helmsing in forum Billing/Reimbursement
    Replies: 1
    Last Post: 08-31-2011, 03:37 PM
  5. Code descriptors
    By debbieplatou in forum Diagnosis Coding
    Replies: 2
    Last Post: 05-05-2010, 01:58 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.