Why was he asked to see this patient? What's the CC? The HPI is supposed to be based on the CC. Seems most of what he has given is ROS. Let's say as a Cardio specialty, he was called in for the Afib
HPI: The pt is a 91 yr old woman admitted yesterday by Dr. Blah for urosepsis and atrial (location) fibrillation (CC) with a rapid ventricular rate response (timing or quality).
She has elevated troponins (Assoc S&S).
The pt is hard of hearing (Neuro or ENT ROS).
The pt has some degree of dementia (Neuro ROS).
Most of the history is based on Dr. Blah note. (Irrelevant- he must perform ROS to get credit for ROS)
However, the pt denied having chest pain or other anginal-like symptoms, CHF signs or symptoms, palpitations, syncope, or near syncope. (all CV ROS)
The pt has no known history of any significant cardiovascular disease. Her cardiovascular risk factors include her age, postmenopausal, hypertension. (all Past History)
You have 3 HPI, 3 ROS, and 1 history so he gets an EPF History.
If you give him credit for duration (admitted yesterday) then he has 4 HPI, 3 ROS and 1 history and he gets a Detailed History. I would not as "admitted yesterday" does not identify when the Afib started. Before admit? After admit? Chronic?
See what other responses you get. These HPI questions always leads to good discussion of what statements meet what bullets
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join