Results 1 to 7 of 7

Hpi-Modifying Factors

  1. #1
    Question Hpi-Modifying Factors
    Exam Training Packages
    A new patient, John Smith, comes into my office for an evaluation following a motor vehicle accident that occurred on 1/3/02. His chief complaints consist of left-sided neck pain and left anterior chest wall pain. The neck and chest pain started a few hours after the accident. The neck pain sometimes radiates into the shoulder and can be sharp in nature. The pain decreases with the use of the heating pad.

    I say the following are each included in the above HPI descriptors?
    Location
    Quality
    Timing
    Context
    Modifying Factors

    The book said context was not in the progress note. What do you think?

  2. #2
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    Quote Originally Posted by pattytpa View Post
    A new patient, John Smith, comes into my office for an evaluation following a motor vehicle accident that occurred on 1/3/02. His chief complaints consist of left-sided neck pain and left anterior chest wall pain. The neck and chest pain started a few hours after the accident. The neck pain sometimes radiates into the shoulder and can be sharp in nature. The pain decreases with the use of the heating pad.

    I say the following are each included in the above HPI descriptors?
    Location
    Quality
    Timing
    Context
    Modifying Factors

    The book said context was not in the progress note. What do you think?
    I see"
    CC/Location = pain (neck/chest)
    Timing = few hours after accident
    Severity = sharp in nature
    Modifying Factors = paint decreases with use of heating pad

    I don't see Quality (unless that's what I'm calling Severity) and I don't see Context either.
    what do you see as Context?

    Thanks!
    Donna, CPC, CPC-H

  3. #3
    Default
    I thought "following a motor vehicle accident that occurred on 1/3/02" would constitute as "context". I gave quality for "sharp in nature"
    Thanks a bunch for the reply.

  4. #4
    Default I agree
    I agree with your assessment that "context" is documented based on the documentation that it follows the accident and I agree with "quality" instead of severity. When dealing with pain, I typically judge "severity" on the 10 scale.
    Belinda S. Frisch, CPC, CEMC
    Author of "Correct Coding for Medicare, Compliance, and Reimbursement"

  5. #5
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    yes, I see the comparison with the "severity"/"quality" - and I'd agree, "sharp" should go under quality. however - I still don't see "context" here. Context is basically - under what circumstances does it occur - which I believe is referring to the CC/issue at hand (eg, the sharp pain only happens when bending to the right - or some other statement to that effect).
    Donna, CPC, CPC-H

  6. #6
    Default
    Thanks for the input!

  7. #7
    Default
    I agree with Donna. I don't see context either.
    Amy Crego, CPC, CPC-P, CPMA, CRC
    Vice President, Columbus, OH AAPC

    One can never consent to creep when one feels an impulse to soar. ~ Helen Keller

Similar Threads

  1. Hpi
    By terricox in forum E/M
    Replies: 2
    Last Post: 03-10-2010, 06:09 PM
  2. HPI Again
    By NESmith in forum Family Practice
    Replies: 3
    Last Post: 03-10-2010, 07:34 AM
  3. Hpi
    By NESmith in forum Family Practice
    Replies: 3
    Last Post: 03-09-2010, 01:53 PM
  4. Hpi
    By dsmith06351 in forum E/M
    Replies: 2
    Last Post: 03-05-2010, 11:42 AM

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?

Login

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.