Wiki HPI Element Quesion

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MichelleAKing

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Dear Fellow Memebers, please see the HPI at the bottom...
I audited this physician's visit and I could only find three elements to give him in his HPI, Location, Quality and Associated Signs and Symptoms. The physician is arguing with me that his statement that "she has been asymptomatic" should be counted as "severity". I disagree with him and would like some feedback as to what some others think. I counted it as associated signs and sympptoms because he is basically saying that she has no symptoms. He views it differently and sees it as since there are no symptoms that is not severe. I tried to explain to him that severity is a descriptive statement describing the severity of the symptoms. Any thoughts would be greatly appreciated. Thank you in advance!

"The patient is a 66-year-old woman who presents for further evaluation of an abdominal aortic aneurysm. She has been asymptomatic from this. She denies any tearing back pain. She denies any distal emboli. She has no symptoms of claudication. She has had no angina and no CVAs. She is otherwise at her baseline state of health. There is no family history of aneurysms."
 
I actually would have only given him credit for location- I would not have given credit for quality or associated signs and symptoms because neither were documented. You cannot get points in a patient's history for listing things that the patient does not have.

I would also ask that if the patient is asymptomatic, what is the chief complaint or medically necessary reason for her visit? And if she is asymtomatic, what further evaluation is needed?
 
The physician asked these questions, based on her/his clinical knowledge inherent of this condition and its anticipated course. In other words, these questions may be all that were necessary in order to determine what further treatment may be needed from this point. Therefore, the absence of all of these symptoms may actually impy that the patient is asymptomatic today. The A/P, the plan - will explain what, if any, further evaluation will be needed in order to keep the patient at baseline and/or to improve the condition. Also being at baseline at this point, means degree or "quality".
 
MichelleAKing said:
Dear Fellow Memebers, please see the HPI at the bottom...
I audited this physician's visit and I could only find three elements to give him in his HPI, Location, Quality and Associated Signs and Symptoms. The physician is arguing with me that his statement that "she has been asymptomatic" should be counted as "severity". I disagree with him and would like some feedback as to what some others think. I counted it as associated signs and sympptoms because he is basically saying that she has no symptoms. He views it differently and sees it as since there are no symptoms that is not severe. I tried to explain to him that severity is a descriptive statement describing the severity of the symptoms. Any thoughts would be greatly appreciated. Thank you in advance!

"The patient is a 66-year-old woman who presents for further evaluation of an abdominal aortic aneurysm. She has been asymptomatic from this. She denies any tearing back pain. She denies any distal emboli. She has no symptoms of claudication. She has had no angina and no CVAs. She is otherwise at her baseline state of health. There is no family history of aneurysms."
Click to expand...

I'll wager an opinion here.

Stating that the patient is asymptomatic is severity. You are detailing the degree of her symptoms.

Hope this helps and again this is my opinion.
 
I'm curious as to whether or not it even makes a difference in the big picture. I would consider this and EPF history, your MDM is going to be stuck at SF (based on dx points) unless they are ordering testing.

This is more a status of a chonic condition in my opinion, than a HPI that you can pull elements from anyway.


Just my thoughts,

Laura, CPC, CPMA, CEMC
 
3 elements

I only get three elements .... location (abdominal aortic), quality (asymptomatic), assoc signs/symptom (no back pain, etc)

If he had said this is a "grade 2" AAA (.... I am making this up for illustration purposes ... have no idea of AAA are classified by grade) ... then I'd give credit for severity.

He might also have said "AAA found on ultrasound" and gotten credit for context.
He might also have said "AAA first noted Dec 2010" and gotten credit for duration.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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