Wiki HPI opinions

[hkatie]

Following is an HPI that came across my desk this morning. I'd like some opinions on whether you would code this as a brief or an extended HPI.

"HPI: This is a 55 year old male who:
has a family history of non-melanoma skin cancer, and is here for a skin check.
The patient is being monitored for the development of new lesions.
1. comes in for a chief complaint of a skin lesion, located on the right hand. The
lesion is new. The lesion has been present for 2 weeks. This lesion has not been
treated in the past. The patient presents today for: further evaluation and
management."

Thanks in advance for your opinion.

 

[btadlock1]

Following is an HPI that came across my desk this morning. I'd like some opinions on whether you would code this as a brief or an extended HPI.

"HPI: This is a 55 year old male who:
has a family history of non-melanoma skin cancer, and is here for a skin check.
The patient is being monitored for the development of new lesions.
1. comes in for a chief complaint of a skin lesion, located on the right hand. The
lesion is new. The lesion has been present for 2 weeks. This lesion has not been
treated in the past. The patient presents today for: further evaluation and
management."

Thanks in advance for your opinion.

I say brief - Location and Duration are present, but I don't see anything else. You might be able to justify Context, but it still doesn't give you enough for extended.

 

[nyyankees]

Following is an HPI that came across my desk this morning. I'd like some opinions on whether you would code this as a brief or an extended HPI.

"HPI: This is a 55 year old male who:
has a family history of non-melanoma skin cancer, and is here for a skin check.
The patient is being monitored for the development of new lesions.
1. comes in for a chief complaint of a skin lesion, located on the right hand. The
lesion is new. The lesion has been present for 2 weeks. This lesion has not been
treated in the past. The patient presents today for: further evaluation and
management."

Thanks in advance for your opinion.

Would 'this lesion has not been treated in the past" allow modifying factors?

 

[MnTwins29]

If allowing for the modifying factors, I still get three - modifying factors, location and duration. I wouldn't be comfortable with context - does family hx count as that?

 

[btadlock1]

If you wanted, you could probably count the family history as context. I thought about the modifying factor, but I don't think that stating that they've never received treatment fits the definition - a modifying factor should either be an effort to produce a change in the status of the problem, or an inadvertent action that results in a change (eg, "modifies" it, in some way) - the fact that they've never sought treatment for a problem (especially one with a duration of only 2 weeks), would only qualify as personal history, in my opinion. (And it's a weak example of that, too).

To count this as extended, I would expect to see documentation of the size, color, whether or not it's painful or has irregular borders, is bleeding/oozing, or if it's growing/changing rapidly. This note gives no indication of the physical characteristics or severity, so it doesn't convey the medical necessity, to support a higher level visit, in the first place - without that foundation, I don't see any justification for an extended HPI, even if there was enough information present in the current note. But, that's just my two cents...

 

[hkatie]

Thanks to all for your input. I'm sure it's easy to guess in the coder-provider pairing, who thought it was extended... Your help is always appreciated. Thanks again.