ED Coding and Reimbursement Alert

Question:A teenager presents with intermittent right sided abdominal pain occurring at least three times per day mostly in the morning for the last week with associated nausea and vomiting. Both parents of the teenager have had their appendixes removed. The patient rates the current pain as eight out of 10, and says it is a sharp, stabbing pain unrelieved by Tylenol. The ED physician performs a physical examination, including a detailed examination of the gastrointestinal system and other related systems including, constitutional, cardiovascular, respiratory, and genitourinary. The physician cannot determine the etiology of the abdominal pain, so the patient is sent for stat labs and a computed tomography (CT) scan of the abdomen. The patient is then asked to follow up the next afternoon for the results. What level of history of present illness (HPI) is this?North Dakota SubscriberAnswer: Your physician performed an extended HPI, as he addressed all of [...]