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How many elements are in this HPI?

  1. Question How many elements are in this HPI?
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    [U]Which HPI elements can you find?[/U] I would really appreciate all responses this. :

    Diagnosis: Infiltrating intraductal carcinoma of the left breast, status post lumpectomy.

    Chief complaint: Left breast cancer.

    History of Present Illness: Mrs. Patient is a 79 year old woman who has a history of fibrocystic breast disease for many years. She has had several aspirations of cyst in her left breast which was always negative. After menopause she stopped getting lumps; however, when she was put on hormonal therapy she began to have fibrocystic disease again. She stopped her hormones due to the presence of cysts and also changes in personality and vaginal bleeding. She underwent screening mammogram this year and an irregularity was found. She was sent for diagnostic mammogram and ultrasound which ultimately lead to her diagnosis. She was referred to Dr. A. Doctor and underwent a lumpectomy on March 19, 2009. Pathology revealed intraductal papillary carcinoma, greatest dimension 0.5 cm, nuclear grade 1, no mitosis seen, proliferative fibrocystic changes, focal adenosis, usual ductal hyperplasia, micro calcification within benign ducts. There was a focus of atypical ductal hyperplasia therefore the margins were re-excised and were ultimately negative. She was seen by Dr. B. Doctor and placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time. The patient is seen today for discussion and evaluation of postoperative radiotherapy to her left breast.

  2. #2
    I come up with

    Location-left breast
    Context-She underwent screening mammogram, an irregularity was found
    Duration-this year
    Modifying Factor-underwent a lumpectomy, placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time

    There could be more but you max at 4 so that is all I really looked for.

    Laura, CPC, CEMC

  3. Default
    So you see no reason that this would not meet at least four elements and it does give a description of the patient's illness in a chronological order from onset of first symptoms until the present?
    I have been told that these elements were not acceptable because it does not describe what that patient is experiencing today (date of consult/np visit). I do not agree with this. What is your opinion on this?
    Tammy L. Mannisto, CPC, ROCC
    Infusion, Hematology/Oncology, Radiation Oncology

  4. #4
    Tampa, Florida
    HPI is a choronological decription tha patients present illness development, fromt he first sign or symptoms, or previous encounter, to the present. so i believe from the description you made can be use as 4 elements for the current HPI. This is exactly how we would document a patients follow up visit.

    hope this helps
    Nickie, CPC

  5. #5
    I have no problem with calling this an Extended HPI. This is the history of the present illness this provider is going to treat. They are dealing with the aftermath of a cancer diagnosis. This is pertinent to that. This describes what is going on and is the reason the patient is there today. This is still an active unresolved issue.

    I guess I don't understand where they are coming from in this view. What do they think it should say? I am at a loss. I consider this a good HPI for this type of visit.

    Laura, CPC, CEMC

  6. Default
    They recently reviewed the consults/np visits and determined that for the HPI (including this one and the other visits which are almost identical) that the only element that we could use is the context for the body of the HPI.

    I truly appreciate your thoughts on this topic. I believe this will help me in my discussion with them.
    Tammy L. Mannisto, CPC, ROCC
    Infusion, Hematology/Oncology, Radiation Oncology

  7. Default
    Thank you for your response, it is very helpful to have another perspective.
    Tammy L. Mannisto, CPC, ROCC
    Infusion, Hematology/Oncology, Radiation Oncology

  8. #8
    Milwaukee WI
    Default I agree with Laura
    I agree with Laura - there are easily 4 elements of HPI here. In addition to what Laura listed, I also identified
    Quality - intraductal papillary carcinoma
    Severity - greatest dimension 0.5 cm

    Who is the "they" who are saying you can only count context? If we were to take the description of HPI as a "chronological description" literally (and to the extreme) then the only thing we could count would be duration.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  9. #9
    Grand Rapids, MI
    I code Hem/Oncology and have struggled with this question. I would count location as breast, lung, etc. If they said what type of cancer I would count that as Quality. If they stage it or say it has mets to another area, I would count severity and then of course, if they would say when it occurred, I would count time. Then I began to question myself that I should not be counting the quality the way I was. Any thoughts?
    Ann Campbell, CPC
    Last edited by abc1099; 11-10-2009 at 08:05 AM.

  10. Default
    The "they" that I am speaking of is our internal auditors. Initially when I coded the consults and new patient visits I found that most of them met the criteria for the highest level of service, which in turn prompted the audit. Upon their review they determined that the physician's services were not meeting the correct levels due to the HPI issue listed above. I did not feel comfortable with their findings; however they are our auditors and therefore it is not the easiest task to disagree with them and prove my point with management who are not coders. I am truly thankful for the feedback, I am in hopes that it will be what is needed to re-evaluate this review.
    Tammy L. Mannisto, CPC, ROCC
    Infusion, Hematology/Oncology, Radiation Oncology

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