
- Tools for documenting HPI
Tools for documenting HPI
-

Time based coding
I am trying to find examples and/or specific guidelines for time based documentation. Any help would be appreciated.
-

Examples help
Doreen,
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
Similar Threads
-
By harleymama4u in forum E/M
Replies: 0
Last Post: 11-07-2015, 01:30 PM
-
By spenning.sp@gmail.com in forum E/M
Replies: 1
Last Post: 10-16-2014, 06:56 AM
-
By akmorgan in forum Medical Coding General Discussion
Replies: 1
Last Post: 08-12-2010, 01:56 PM
-
By Mjones7 in forum Medicare Regulations
Replies: 1
Last Post: 10-24-2009, 03:49 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
-
Forum Rules