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Tools for documenting HPI

  1. Default Time based coding
    Medical Coding Books
    I am trying to find examples and/or specific guidelines for time based documentation. Any help would be appreciated.

  2. #12
    Milwaukee WI
    Default Examples help
    Maybe an example will help:

    Patient fell off swing yesterday, and noted immediate sharp pain in left wrist. This morning wrist is noticeably swollen and bruised.
    Here you have 4 elements of HPI -
    Duration - yesterday
    Quality - sharp
    Location - left wrist
    Assoc sign - swollen, bruised

    OR ...

    Patient with intermittent chest pain for past two days, described as "mild, more like tightness," worse with exercise such as going up stairs
    This gives up 5 HPI elements (you only need 4 for highest level)
    Timing - intermittent
    Location - chest
    Duration - two days
    Quality - mild
    Context - worse w/ exercise

    Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example).

    Good luck!

    F Tessa Bartels, CPC, CPC-E/M

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