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How many elements are in this HPI?

  1. #11
    Default Get an unbiased outside opinion
    Medical Coding Books
    Many coding/auditing companies will do a sample audit for free since they are trying to get your business. They will do a formal audit of your records and write a report of their findings. That would give you more support as well.

    Side note, not that anything on here was biased but the fact it came from you and supports your point can be seen as biased by those who disagree with your stance.

    Laura, CPC, CEMC

  2. Default
    Thank you both are very good points. I know that the physicians are requesting an outside audit be performed and I am in agreeance with them. I will share the information with my manager.
    I had not thought about the fact that it may seem biased, valid point I will keep this in mind.
    Tammy L. Mannisto, CPC, ROCC
    Infusion, Hematology/Oncology, Radiation Oncology

  3. #13
    Houston Med Center
    I've read the replies and some of the answers are questionable.

    Duration- this year; that is when she underwent a screening mammogram—isn't this a definition of Past History? Past History describes the patients past treatments and operations.

    When we look at Modifying factors, we look for indications of what made the problem better or worse. “The patient isn't having a problem with Tamoxifen”—however, the physician doesn't state if it is making the cancer better.

    How do you classify the HPI Tude?

  4. #14
    The 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. It includes the following elements:
    • location,
    • quality,
    • severity,
    • duration,
    • timing,
    • context,
    • modifying factors, and
    • associated signs and symptoms.

    The above is from the 97 Guidelines. This was the first time this patient was ever seen by this provider. The mam is when the first sign of a problem showed up, which based on the above meets the definition of an HPI element. I know I may get some flack for this next statement but I don't see where it says "modifying factors and their effectiveness" anywhere in the guidelines. It simply says "modifying factors".

    I get a bit defensive about this type of HPI because I have specialists that deal with these type of issues. You don't get a nicely categorized "sore throat for 2 days, hurts to swallow, uses cough drops but they don't help" type HPI because the issue was discovered and treated by someone else then that doesn't work so they send them to the specialist. So the specialists HPI is everything from the moment of discovery up to the point they see the patient.

    Ok, maybe I get a lot defensive. It is hard enough for the doctors to do their jobs as it is. We don't need to make it any harder by trying to fit them in a box that they don't belong in. I think this is a great HPI and the provider deserves credit for it. I don't say this to be argumentative it is just my job to defend providers when they are right and to teach them the right way when they are not. If you can show me how this is wrong based on the guidelines themselves I will gladly back down.

    Laura, CPC, CEMC

  5. #15
    North Carolina
    Thumbs up Defensive? Naahhh-Passionate

    If I could...I would add points to your reputation, again, but can't. Must be too early to give you "points" again. WHY IS THAT??


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