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Can you find more than 3 elements in HPI?

  1. #1
    Default Can you find more than 3 elements in HPI?
    Medical Coding Books
    Good morning all!

    I am having problems finding an extra bullet to get 4 HPI elements and was wondering if any of you can find an extra one for this new patient evaluation.

    HPI: The patient is a 44-year-old female who is seen today for a new left breast mass. This was discovered on routine screening mammography, which prompted an ultrasound that confirmed a 5.8 x 7.8 x 4 mm mass in the left breast, BI-RADs 4. The radiologist did commonet on the density of her breast, which made comparison difficult; however, this lesion wsa not appreciated on a mammogram one year prior. She denies any breast pain, nipple discharge, or palpable masses on self-breast exam. She has no family history of breast malignancy. She has regular menstrual cycles, beginning at age 15. She has used BCP in thep ast, but none recently.

    This is what I get:
    Loc--left breast mass.
    Context--radiologic findings.
    Assoc--no breast pain, nipple discharge..etc.

    Is there one more that I am missing??

    Thanks for your help!

  2. Default
    Left breast is the location, but the mass is the quality.

  3. Default
    I found only 3 elements.

    Location: left breast
    context: routine screening mammogram
    assoc sign & sypmptoms: 5.8 x 7.8 x 4 mm mass.

    modifying factor: "lesion was not on a mammogram one year prior"

    Modifying factor...some may count it, it's all up for interpretation.

    if the dr gave more detail on the breast denisity you could count it as quality.

    good luck!
    Last edited by deeva456; 07-10-2009 at 02:58 PM.

  4. #4
    What about duration, it was discovered on her routine mam, wasn't there last year. Or modifying factor BCP used in the past?

    Laura, CPC

  5. #5
    My version is as follows:

    Duration: New
    Location: Left Breast
    Context: Routine screening mammography
    Severity: 5.8 x 7.8 x 4 mm
    (maybe) Modifying Factor: BCP
    (maybe) Quality: Density of her breast

    Hope this is useful.
    Karolina, CPC, CPMA, CEMC

  6. #6
    Milwaukee WI
    Default 4 HPI elements
    Location: left breast
    Context: discovered on mammogram
    Duration: wasn't there a year ago
    Associated sign: no breast pain or nipple discharge

    F Tessa Bartels, CPC, CEMC

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