# Need help with getting HPI elements



## mcarrillo (Jan 13, 2012)

Hi I have a doc who wants to bill a 99254, inpt consult on this note. I can't get enough HPI elements though. We go by the 1995 guidelines. I'd appreciate any thoughts, suggestions, feedback. 

See below note,
Thanks.
__________________________________________________________________________


INPATIENT SURGERY CONSULT NOTE


1/10/2012

5:51 PM


Reason for Consult
is a 59 year old year old female new patient to me requested by , MD. History was obtained from transfer records. I was asked  urgently to consult for poss cholecystitis 




Review of patient's allergies indicates:
No Known Allergies

Outpatient Prescriptions Marked as Taking for the 1/9/12 encounter (Hospital Encounter) 
Medication Sig Dispense Refill 
• albuterol (PROAIR HFA) 108 (90 BASE) MCG/ACT inhaler Inhale 2 Puffs into the lungs every four hours as needed for Wheezing and Shortness of Breath.  1 Inhaler  6 
• butalbital-aspirin-caffeine (FIORINAL) 50-325-40 MG per capsule Take 1 Cap by mouth every four hours as needed for Headache.  40 Cap  0 
• fluticasone (FLONASE) 50 MCG/ACT nasal spray Use 2 Sprays in the nostril(s) daily.  16 g  1 
• NEW DRUG Apply  topically. Use COCK UP WRIST SPLINT ON RIGHT WRIST AT NIGHT 
DX: cts  1 Unit  0 
• SOMA 350 MG PO TABS prn     
• VICODIN 5-500 MG PO TABS 1 TABLET EVERY 4 TO 6 HOURS AS NEEDED     



Past Medical History 
Diagnosis Date 
• Arthritis   
    RA and anklizing spondilosis 
• MRSA (methicillin resistant Staphylococcus aureus)   
    rt axilla 
• RA (rheumatoid arthritis) 8/16/2010 
• Asthma 8/16/2010 
• GERD (gastroesophageal reflux disease) 10/26/2010 
• CTS (carpal tunnel syndrome) 3/8/2011 




Past Surgical History 
Procedure Date 
• Appendectomy (hx question)   
• Cataract extr (hx question)   
    due to steroid injections for AS 
• Other surg hx(hx only)   
    ulna nerve surgery 
• Colonoscopy 2004 
    normal 




History 


Social History 
• Marital Status: Divorced 
    Spouse Name: N/A 
    Number of Children: N/A 
• Years of Education: N/A 


Occupational History 
• Not on file. 


Social History Main Topics 
• Smoking status: Never Smoker  
• Smokeless tobacco: Not on file 
• Alcohol Use: No 
• Drug Use: No 
• Sexually Active: Not on file 


Other Topics Concern 
• Not on file 


Social History Narrative 
• No narrative on file 




Family History 
Problem Relation Age of Onset 
• Heart Disease Mother   
• Stroke Father   
• Diabetes Father   
• Arthritis Other   
    AS 





Review of Systems
A comprehensive review of systems was negative.


Vitals
Blood pressure 100/60, pulse 63, temperature 97.5 Â°F (36.4 Â°C), temperature source Oral, resp. rate 18, height 1.702 m (5' 7"), weight 70 kg (154 lb 5.2 oz), SpO2 96.00%.


Physical Exam
She is alert. She appears in no distress.
Skin shows skin color, texture, turgor normal. No rashes or lesions..
HEENT: mucous membranes moist and PERRL.
Lungs are clear to auscultation and with good chest wall expansion.
Heart has RRR (regular rhythm and rate). The PMI is not examined. Ascultation reveals an S1 and S2.
Abdomen: abdomen normal
Extremities appear normal. 
Neuro: negative


Labs:
Most Recent Result (within the last 72 hours)
Result Component Current Result 
Hematocrit 36.0 (1/10/2012) 
HEMOGLOBIN 12.0 (1/10/2012) 
PLT CNT 290 (1/10/2012) 
WBC 10.1 (1/10/2012) 

, Most Recent Result (within the last 72 hours)
Result Component Current Result 
BUN 9 (1/10/2012) 
CREATININE 0.6 (1/10/2012) 
NA 142 (1/10/2012) 
POTASSIUM 4.0 (1/10/2012) 

.


Imaging Studies:








Assessment:
Principal Problem:
 *Dilated cbd, acquired
Active Problems:
 AS (ankylosing spondylitis)
 Migraine
 GERD (gastroesophageal reflux disease)
 OA (osteoarthritis)
 Cholelithiasis NOS

Current medical conditions or issues: no significant and see PMI &/or Problem List.


Plan:
Further  testing: none.
Medications recommended: none.
Medical follow up: will follow while hospitalized doubt cholecystitis to review us


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## ajs (Jan 16, 2012)

mcarrillo said:


> Hi I have a doc who wants to bill a 99254, inpt consult on this note. I can't get enough HPI elements though. We go by the 1995 guidelines. I'd appreciate any thoughts, suggestions, feedback.
> 
> See below note,
> Thanks.
> ...



From the note as listed, there is not enough for that level of visit.  There are a lot of references to other records that are not listed here, but still think there needed to be more actual documentation of the problem and the assessment.


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## LLovett (Jan 17, 2012)

*I don't see any HPI*

I would go with a subsequent care code on this and drop the history from the level selection. They just barely got a CC to support a visit at all.

Laura, CPC, CPMA, CEMC


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## dimmitta (Jan 17, 2012)

*Hpi?*

I agree with Laura, there are no HPI elements here, so I would also go with a subsequent day. Also, this would be a good example to hang onto for whoever does your Physician education regarding documentation requirements.


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## mcarrillo (Jan 17, 2012)

Thank you Ladies,

This helps me out tremendously, I have something substantial to show staff and the providers.


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