# How many elements are in this HPI?



## Tammytude (Nov 6, 2009)

[*U]Which HPI elements can you find?[/U]  I would really appreciate all responses this. :*


Diagnosis: Infiltrating intraductal carcinoma of the left breast, status post lumpectomy. 

Chief complaint: Left breast cancer. 

History of Present Illness: Mrs. Patient is a 79 year old woman who has a history of fibrocystic breast disease for many years. She has had several aspirations of cyst in her left breast which was always negative.  After menopause she stopped getting lumps; however, when she was put on hormonal therapy she began to have fibrocystic disease again.  She stopped her hormones due to the presence of cysts and also changes in personality and vaginal bleeding.  She underwent screening mammogram this year and an irregularity was found.  She was sent for diagnostic mammogram and ultrasound which ultimately lead to her diagnosis.  She was referred to Dr. A. Doctor and underwent a lumpectomy on March 19, 2009.  Pathology revealed intraductal papillary carcinoma, greatest dimension 0.5 cm, nuclear grade 1, no mitosis seen, proliferative fibrocystic changes, focal adenosis, usual ductal hyperplasia, micro calcification within benign ducts.  There was a focus of atypical ductal hyperplasia therefore the margins were re-excised and were ultimately negative.  She was seen by Dr. B. Doctor and placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time.  The patient is seen today for discussion and evaluation of postoperative radiotherapy to her left breast.


----------



## LLovett (Nov 6, 2009)

I come up with

Location-left breast
Context-She underwent screening mammogram, an irregularity was found 
Duration-this year
Modifying Factor-underwent a lumpectomy, placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time

There could be more but you max at 4 so that is all I really looked for.

Laura, CPC, CEMC


----------



## Tammytude (Nov 6, 2009)

So you see no reason that this would not meet at least four elements and it does give a description of the patient's illness in a chronological order from onset of first symptoms until the present?    
I have been told that these elements were not acceptable because it does not describe what that patient is experiencing today (date of consult/np visit).  I do not agree with this.  What is your opinion on this?


----------



## codernickie (Nov 6, 2009)

HPI is a choronological decription tha patients present illness development, fromt he first sign or symptoms, or previous encounter, to the present.  so i believe from the description you made can be use as 4 elements for the current HPI.  This is exactly how we would document a patients follow up visit.  

hope this helps
Nickie, CPC


----------



## LLovett (Nov 6, 2009)

I have no problem with calling this an Extended HPI. This is the history of the present illness this provider is going to treat. They are dealing with the aftermath of a cancer diagnosis. This is pertinent to that. This describes what is going on and is the reason the patient is there today. This is still an active unresolved issue. 

I guess I don't understand where they are coming from in this view. What do they think it should say? I am at a loss. I consider this a good HPI for this type of visit.

Laura, CPC, CEMC


----------



## Tammytude (Nov 6, 2009)

They recently reviewed the consults/np visits and determined that for the HPI (including this one and the other visits which are almost identical) that the only element that we could use is the *context for the body of the HPI. * 

I truly appreciate your thoughts on this topic.  I believe this will help me in my discussion with them.


----------



## Tammytude (Nov 6, 2009)

Thank you for your response, it is very helpful to have another perspective.


----------



## FTessaBartels (Nov 9, 2009)

*I agree with Laura*

I agree with Laura  - there are easily 4 elements of HPI here. In addition to what Laura listed, I also identified 
*Quality* - intraductal papillary carcinoma
*Severity* - greatest dimension 0.5 cm

Who is the "they" who are saying you can only count context?  If we were to take the description of HPI as a "chronological description" literally (and to the extreme) then the only thing we could count would be duration.

Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## abc1099 (Nov 10, 2009)

I code Hem/Oncology and have struggled with this question.  I would count location as breast, lung, etc.  If they said what type of cancer I would count that as Quality.  If they stage it or say it has mets to another area, I would count severity and then of course, if they would say when it occurred, I would count time.  Then I began to question myself that I should not be counting the quality the way I was.  Any thoughts?
Ann Campbell, CPC


----------



## Tammytude (Nov 11, 2009)

The "they" that I am speaking of is our internal auditors.  Initially when I coded the consults and new patient visits I found that most of them met the criteria for the highest level of service, which in turn prompted the audit.  Upon their review they determined that the physician's services were not meeting the correct levels due to the HPI issue listed above.  I did not feel comfortable with their findings; however they are our auditors and therefore it is not the easiest task to disagree with them and prove my point with management who are not coders.  I am truly thankful for the feedback, I am in hopes that it will be what is needed to re-evaluate this review.


----------



## LLovett (Nov 11, 2009)

*Get an unbiased outside opinion*

Many coding/auditing companies will do a sample audit for free since they are trying to get your business. They will do a formal audit of your records and write a report of their findings. That would give you more support as well.


Side note, not that anything on here was biased but the fact it came from you and supports your point can be seen as biased by those who disagree with your stance.

Laura, CPC, CEMC


----------



## Tammytude (Nov 11, 2009)

Thank you both are very good points.  I know that the physicians are requesting an outside audit be performed and I am in agreeance with them.  I will share the information with my manager. 
I had not thought about the fact that it may seem biased, valid point I will keep this in mind.


----------



## Dicey (Nov 11, 2009)

I've read the replies and some of the answers are questionable.

Duration- this year; that is when she underwent a screening mammogram—isn't this a definition of Past History?  Past History describes the patients past treatments and operations.

When we look at Modifying factors, we look for indications of what made the problem better or worse.  “The patient isn't having a problem with Tamoxifen”—however, the physician doesn't state if it is making the cancer better.

How do you classify the HPI Tude?


----------



## LLovett (Nov 12, 2009)

HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient's present
illness from the first sign and/or symptom or from the previous encounter to the
present. It includes the following elements:
• location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.

The above is from the 97 Guidelines. This was the first time this patient was ever seen by this provider. The mam is when the first sign of a problem showed up, which based on the above meets the definition of an HPI element. I know I may get some flack for this next statement but I don't see where it says "modifying factors and their effectiveness" anywhere in the guidelines. It simply says "modifying factors".

I get a bit defensive about this type of HPI because I have specialists that deal with these type of issues. You don't get a nicely categorized "sore throat for 2 days, hurts to swallow, uses cough drops but they don't help" type HPI because the issue was discovered and treated by someone else then that doesn't work so they send them to the specialist. So the specialists HPI is everything from the moment of discovery up to the point they see the patient. 

Ok, maybe I get a lot defensive. It is hard enough for the doctors to do their jobs as it is. We don't need to make it any harder by trying to fit them in a box that they don't belong in. I think this is a great HPI and the provider deserves credit for it. I don't say this to be argumentative it is just my job to defend providers when they are right and to teach them the right way when they are not. If you can show me how this is wrong based on the guidelines themselves I will gladly back down.

Laura, CPC, CEMC


----------



## RebeccaWoodward* (Nov 12, 2009)

*Defensive?  Naahhh-Passionate*

Laura,

If I could...I would add points to your reputation, again, but can't.  Must be too early to give you "points" again.  WHY IS THAT??

Anyway...


----------

