# Opinions please--how many HPI elements can you find?



## coder25 (Aug 22, 2010)

Hello all,

Need help in deciding whether this has 4 elements or less.  I feel there are four, however, a recent prospective auditor felt that there were not four.  How many do you get?  


Chief Complaint:  Longstanding history of morbid obesity.

HPI:  The patient is seen today due to a longstanding history of morbid obesity.  He has tried various attempts at weight loss including Weight Watchers, Atkins Diet, Jenny Craig, etc. without success.  His comorbities include obstructive sleep apnea, diabetes mellitus, hypertension and arthritis of knees and feet.  

This is what I get....


Duration:  Longstanding history

Quality:  Morbid

Signs/symptoms:  Sleep apnea, diabetes, hypertension, and arthritis.

Modify factors:  Various attempts at weight loss. 

Location:  Can *obesity* be used as a location????


Thanks in advance for your help.


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## lecrutch (Aug 22, 2010)

*HPI elements*

Coder25:

Which element did the auditor question?  Obesity?  Probably not medically considered a location. 

I also don't believe counting weight loss programs as a modifying factor would be an HPI element; although "unsuccessful," how was they obesity "modified?" Did they cause additional weight gain or possibly only slight weight loss which the patient didn't consider fast enough and therefore unsuccessful...  If the physician had added this comment, I'd be more likely to count it.  I do realize, however, the credit was probably allowed just for stating "unsuccessful." I'd have been more comfortable with a statement of causing extreme exhausting or SOB with activity, therefore negating exercise.

Also, the doctor mentioned 4 chronic illnesses associated with the diagnosis of diabetes; sleep apnea, diabetes, hypertension and arthritis,  If the physician had only mentioned if these were stable or worsening, I'd allow credit for mentioning the status of "three chronic or inactive problems..." under the '97 guidelines thus allowing an extended HPI without question.

Once again what should be black and white just isn't.  Having stated my opinion above if I felt strongly obesity was a location I'd fight for it as being a logical location of the body in general!

Hopefully the answer was arrived at in the review of medical decision making.  Since the obesity is not worsening, without justification for moderate or high decision making, you likely won't qualify for more than a problem focused hx and exam, and end up back at a brief HPI anyway.

Good Luck!


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## coder25 (Aug 22, 2010)

Yes, it was the obesity.  I realize that it is not an "exact location", but it is the "problem" for the patient.  As for the MDM, the patient was scheduled for Lap Roux-En-Y bypass and the PE was comprehensive.  I had this discussion at a conference that Highmark Medicare was having and they stated that it was okay to use the obesity as the location/problem as well as the various attempts at weight loss.   The auditor still did not agree with me or with what the person from Highmark Medicare said.  

Thanks for your help!  

Peggy


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## sbicknell (Aug 22, 2010)

_Chief Complaint: Longstanding history of morbid obesity.

HPI: The patient is seen today due to a longstanding history of morbid obesity. He has tried various attempts at weight loss including Weight Watchers, Atkins Diet, Jenny Craig, etc. without success. His comorbities include obstructive sleep apnea, diabetes mellitus, hypertension and arthritis of knees and feet. _

Duration:  long-standing
Severity:  morbid
Mod Factors:  WW, Atkins, JC
Assoc S&S:  OSA, DM, HTN, arthritis

Mod Factors are what the patient has done that affects the CC, either making it worse or better. That the weight programs were unsuccessful does not eliminate them as a Mod Factor.  Just as I would count a patient with an URI that "has tried OTC meds with no relief" as a Mod Factor

I would not count obesity as a location unless he specified that weight was predominately distributed around the chest vs around the hips or something like that. Apparently "apple" weight is more serious than "pear" weight

If this is a new problem to this physician, then I would give him 4 HPI bullets.  If this was an old problem to this physician then I would give him status of 1 chronic condition

What did the auditor get or count?


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## coder25 (Aug 23, 2010)

sbicknell said:


> _Chief Complaint: Longstanding history of morbid obesity.
> 
> HPI: The patient is seen today due to a longstanding history of morbid obesity. He has tried various attempts at weight loss including Weight Watchers, Atkins Diet, Jenny Craig, etc. without success. His comorbities include obstructive sleep apnea, diabetes mellitus, hypertension and arthritis of knees and feet. _
> 
> ...



The auditor found only three.  She will be calling me to go over what she found and why and to discuss why I chose the levels that I did. Like I stated earlier, a Highmark Medicare representative did state that I could use obesity as a location/problem, even though it is not an exact location.  Therefore, this is how I have been coding our new bariatric patients who will be undergoing surgery for the obesity.  Now I am concerned that all this time, this has been done incorrectly.  So much for getting correct info from a medicare rep!

Thank you for responding.  I really appreciate it. 

Peggy


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## Peter Davidyock (Aug 23, 2010)

It's one and
Obesity is a condition, not a location.


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## FTessaBartels (Sep 9, 2010)

*You don't need location*

I would not count "morbid obesity" as location.

But you don't need it.  You have already identified four elements - duration, severity (or quality), modifying factors, and associated signs/symptoms.

F Tessa Bartels, CPC, CEMC


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