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E/m - Hpi

  1. Default E/m - Hpi
    Medical Coding Books
    Does anyone give any "weight" to merely listing the medical problems for the HPI? Per '95 guidelines, 1-3 descriptive elements constitutes a BRIEF HPI and 4 or more constitutes an EXTENDED. But if they list 4 problems without any descriptive elements, would you still count that as 4?

    Thanks in advance!

  2. #2
    Greeley, Colorado
    No - the current status of the chronic condition(s) must be documented. For example: "hypertension well controlled on current medication; DM sugars fluctuating" would indicate the current status of two chronic conditions to establish a brief HPI. Hope that helps.

  3. Default Thanks Lisa
    Thanks Lisa. It does!

  4. #4
    Milwaukee WI
    Default HPI vs Med Decision Making
    The HPI consists of the following elements:
    Location, Severity, Modifying factors, Quality, Timing /Duration, Context, Associated signs & symptoms

    Patient states fell off swing and immediately had sharp pain in left leg.
    Gives you location (left leg), quality (sharp), and context (fell off swing)

    If you added the fact that patient fell off swing yesterda
    you'd have a fourth element.

    The status of chronic conditions comes into play for Medical Decision Making.
    F Tessa Bartels, CPC-E/M

  5. #5
    Garden State Chapter, Cherry Hill, NJ
    Using the 1997 guidelines, you can get credit for an extended HPI by stating the status of 3 chronic conditions in lieu of the "traditional" 8 components of HPI.
    As a side note, our local carrier, National Government Services, has stated that they will accept status of 3 chronic conditions that you are managing with either the 1995 or 1997 guidelines.

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