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Thread: E&M

  1. #1
    Join Date
    Apr 2007

    Default E&M

    AAPC: Back to School
    I have just started coding E&M services and need help with some definitions.
    Within the HPI, could someone give me a description of the terms:

    1) location
    2) quality
    3) severity
    4) duration
    5) timing
    6) context
    7) modifying factors
    8) associated signs and symptoms

  2. #2
    Join Date
    Apr 2007
    North Carolina


    B. History of Present Illness
    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.


  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    Good job Rebecca! I like it.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Join Date
    Apr 2007


    Thank you so much!!!!

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Each element defined with a question

    Location - Where - the site, is it diffuse, localized?

    Quality - What kind - sharp, dull, constant, intermittent

    Severity - How bad is it - pain scale 1-10, mild, severe

    Duration - How long has it been present - since yesterday, for 2 weeks, fell on Tuesday

    Timing - Is there a pattern - every morning, continuous, repetitive

    Context - What Brings it on - with exercise, when standing, noted on X-ray

    Modifying factors - What makes it better or worse - better with Tylenol, Rx had no effect

    Associated Signs - What comes with it - other symptoms that accompany the chief complaint.

    Hope that helps
    F Tessa Bartels, CPC, CEMC

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