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Can any get higer level?

  1. #1
    Default Can any get higer level?
    Medical Coding Books
    Hello I can only get an Expanded problem focused from this E&m Due to HPI Can anyone see anything I am missing.
    thx
    CC: As per your request, I saw your patient, in consultation on September 15, 2009. As you know, she is a 58-year-old female who is asymptomatic.

    HPI: The patient is a 58 year old female who had a CT scan to evaluate her aorta, because her siblings and mother had abdominal aortic aneurysms. She was found to have a dilated ascending aorta on CT scan.

    PMH: Past medical history reveals breast cancer and asthma.

    PSH: Past surgical history reveals she had a breast lumpectomy.

    MEDICATIONS: Medications include Arimidex.

    FH: Family history reveals a history of aneurysms. Mother and father had heart disease. Brother had AAA. Sister has scoliosis and hepatitis C.


    SH: Social history reveals she is unemployed. She is married and lives with her husband. She is a former smoker and she has 14 drinks per week.

    ROS: Review of systems revealed she complains of weight gain, seasonal allergies, arthralgia and stiffness. She has not had a blood transfusion. Remainder of the review of systems was negative

  2. #2
    Default
    I agree with you, there is not much in the way of HPI elements to start with and I am actually going into the HPI to get a chief complaint so there is not much you can pull after that.

    All I can get is location (ascending aorta) context ( on CT scan) and pertinent negative assosciated signs and symptoms (asymptomatic) and I will admit this is may be considered stretching it by some. If they would have documented the size of the aorta that could have been severity which would have gotten you the 4 element of HPI. I am not counting the "because her siblings and mother had abdominal aortic aneurysms" as a modifying factor (which many will probably say would be stretching it as well) because I used that as part of the chief complaint.

    Just my take on it,

    Laura, CPC, CEMC

  3. #3
    Default
    My thoughts exactly with trying to use the part about her siblings is def stretching it. thanks so much .. Looks like a down code to me. Dr of course puts 99245 ....

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default possible 4th element
    CC: As per your request, I saw your patient, in consultation on September 15, 2009. As you know, she is a 58-year-old female who is asymptomatic (Assoc sign/symptom).

    HPI: The patient is a 58 year old female who had a CT scan to evaluate her aorta(CHIEF COMPLAINT), because her siblings and mother had abdominal aortic aneurysms. She was found to have a dilated (quality) ascending aorta(location) on CT scan(Modifying factor).

    The only thing I added to what Laura had is quality for "dilated" ... but that's a stretch as well.

    I'd be more inclined to NOT give credit for the detailed history because this is so weak and we really have to stretch for every element.

    F Tessa Bartels, CPC, CEMC

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