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Where Would You Count This in HPI?

  1. #1
    Default Where Would You Count This in HPI?
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    Hello:

    I would appreciate opinions on where you would count these statements.

    Where would you count the following statement in HPI?
    "denies any significant pain in this area". Assoc. S/S, Quality, or neither. The doc wants quality.

    Where would you count the following statement in HPI?
    "developed small tiny ulcer". Severity, Assoc. S/S or neither. The doc wants severity.

    Thank you in adavance for your feedback!
    Jill Tom, COC, CPC, CPMA, CPC-I
    East Valley Kachina Coders
    East Valley Mesa, AZ AAPC Local Chapter
    President 2011
    President-Elect 2010
    New Member Development Officer 2009
    jillmtom@yahoo.com

  2. Default
    "denies any significant pain" - would that be the same as "0" on a scale of 0-10? I would use it as severity.

    "developed small tiny ulcer" - without more info cant say severity - where is the ulcer? If just a general comment could be associated s/s or if he is talking gastric could be severity

  3. #3
    Default
    Based on the information you give I would say that:
    - "denies any significant pain" should be part of the ROS - constitutional to be specific.
    - "developed small tiny ulcer" would support severity in the HPI, namely because of "small, tiny".
    Is this all the documentation you have to work with?
    Karolina, CPC, CPMA, CEMC

  4. #4
    Default
    Hi Karolina:

    Yes there is more. Both of these statments came from the same note. Here is the entire HPI.

    Over the last couple of days the patient states he developed a small tiny ulcer on the left distal first toe. This measures only a couple of mm in diameter. He does not recall any trauma to this area, but he is not sure. He denies any significant pain in this area. No erythema.

    Thanks to all of you for looking this over.
    Jill Tom, COC, CPC, CPMA, CPC-I
    East Valley Kachina Coders
    East Valley Mesa, AZ AAPC Local Chapter
    President 2011
    President-Elect 2010
    New Member Development Officer 2009
    jillmtom@yahoo.com

  5. #5
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    Here is my two cents. . .

    Over the last couple of days the patient states he developed a small tiny ulcer on the left distal first toe. This measures only a couple of mm in diameter. He does not recall any trauma to this area, but he is not sure. He denies any significant pain in this area. No erythema.

    HPI
    last couple of days - Duration
    small tiny, couple mm in diameter - Quality
    left distal toe - Location

    ROS
    denies any significant pain - Musculoskeletal
    no erythema - Integumentary

    Now, some might use the "no erythema" as the 4th HPI for associated signs and symptoms. However, in this case it won't make a difference unless he has additional ROS documented elsewhere that will be counted.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013
    angela@medicalrevenuesolutions.com

  6. #6
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    I can see where the physician might want to consider this statement as referring to quality, if the key word he is focusing on is "significant" pain. Which would suggest that there is some pain. However, quality has also been documented in the details about the lesion.

  7. #7
    Default
    I would be really tempted to count the "He does not recall any trauma to this area, but he is not sure." as context, the doctor tried to get the information and it is a pertinent negative in my opinion.

    Laura, CPC

  8. #8
    Default
    I agree with Angela and Laura. As I was reading the whole paragraph I made the same conclusions, esp. reg. 2 ROS items. The only difference is I would consider "small, tiny & only a couple of mm" severity, because this really describes the size of the ulcer and how bad (or not) it is. But there is at times a very fine line between quality and severity - important is that you count it only once.
    Karolina, CPC, CPMA, CEMC

  9. Default
    Quote Originally Posted by jillmtom View Post
    Hi Karolina:

    Yes there is more. Both of these statments came from the same note. Here is the entire HPI.

    Over the last couple of days the patient states he developed a small tiny ulcer on the left distal first toe. This measures only a couple of mm in diameter. He does not recall any trauma to this area, but he is not sure. He denies any significant pain in this area. No erythema.

    Thanks to all of you for looking this over.
    Duration-last couple of days
    Quality-small, tiny
    Severity-couple of mm in diameter
    S/S--no erythema

    Just IMO

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