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new coder needs help with HPI

  1. #1
    Default new coder needs help with HPI
    Medical Coding Books
    cc: nausea and vomiting and dehydration.

    Patient denies any sick contacts or recent travel. She has had no fevers, chills or diarrhea. patient had a normal bowel movement last night.

    How many elements could I use from this?

    Any help is appreciated. Thank you.

  2. Default Hpi
    I would give only two - associated signs and symptoms and location. What othe opinions have you received? How many did you count?

  3. Default
    who documented the CC? If it was not the MD you can't count it in the HPI.

    I see 4 here in what is documented. Context, timing, Associated, and Modifying factors.

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default 4 or more
    Vomiting and dehydration are NOT context ...

    Denies sick contacts or travel - CONTEXT
    No fever, chills, diarrhea - ASSOC SIGN
    Normal - QUALITY
    Bowel Movement - LOCATION
    Last Night - DURATION

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default
    I see four..........

    associated s & s
    modifiying factor
    quality
    timing

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