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E/M hpi/ Modifying factors question....

  1. #1
    Question E/M hpi/ Modifying factors question....
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    In the HPI for a consult, my question is: when the Dr is stating the kind of surgery the pt just had or what they recently went though in surgery, can I use this as a modifying factor to count as 1 of my hpi elemtns?
    I know if they pt has taken tylenol or put ice on their leg,or whatever the patient has tried to do to relieve their pain, that considers modifying factors. Thanks!!!

  2. #2
    Milwaukee WI
    Default It depends
    It depends on whether the surgery was for treatment of the chief complaint for THIS visit.

    For example if the patient comes in with a sprained ankle and as part of the history you note that the patient had an appendectomy performed 2 weeks ago that would NOT be a modifying factor to the newly sprained ankle.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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