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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
    Location
    Milwaukee WI
    Posts
    4,466
    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
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    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
    Coder

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

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