Results 1 to 4 of 4

History Element

  1. #1
    Default History Element
    Medical Coding Books
    If a patient presented with URI symptoms and gives the below history, would you use "daughter sick with strep" as family history?

    URI: SAMANTHA WARNER complains of URI symptoms.
    SYMPTOMS: Sweats. Sinus Pain. Nasal Congestion. Rhinorrhea. Sore throat. Hoarse voice. Cough productive of sputum. Chest tightness/wheezing.
    ASSOCIATED SYMPTOMS: Nausea/vomiting. Fatigue.
    ONSET: 1weeks ago.
    SEVERITY: Moderate
    PROGRESSION: Getting worse
    Other medications: Theraflu and salt water
    Daughter sick with strep.

  2. #2
    Milwaukee WI
    Default Yes
    I could argue that the physician is looking for "sick contacts" ... i.e. close family members also presenting with some possibly infectious process.

    Yes, I would count "daughter sick with strep" as family history in this scenario.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Overland Park, KS
    On a personal note here, it appears to me that you have listed this patient's name in your post. You might want to remove it. I'm not sure but it could be considered a HIPAA violation by posting it here.

    Just a thought....
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  4. #4
    Could you also argue that it could count as 'context' in the elements of HPI?
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

Similar Threads

  1. HPI Element - I would like to use
    By Suriya Narayanan in forum Emergency Department
    Replies: 3
    Last Post: 03-21-2014, 02:40 AM
  2. Replies: 4
    Last Post: 10-29-2012, 02:26 PM
  3. element -quality
    By drsunitha in forum E/M
    Replies: 0
    Last Post: 08-14-2011, 11:47 PM
  4. Element(s) of CC to ROS
    By 20Hiker16 in forum E/M
    Replies: 2
    Last Post: 10-21-2010, 04:35 PM
  5. History Element for data
    By dzarick1 in forum E/M
    Replies: 1
    Last Post: 01-19-2010, 12:26 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.