Wiki New coder help with HPI

[lhurd02]

Based on Dr. progress notes : Throat pain. pt c/o sore throat x 1 day. girlfriend w / recent + strep.

adding up my pts to HPI can I count this as 4.
Location, associated sign and symptoms, timing, and context or is that a stretch?

 

[purplescarf23]

Chief complaint is pain
Throat is your location +1
Sore is your associated signs and symptons
Duration is x1 day
Context is girlfriend with strep

So Yes in my opinion you would count this as four. I dont think its stretching it.

Kelsey, CPC

 

[btadlock1]

Chief complaint is pain
Throat is your location +1
Sore is your associated signs and symptons
Duration is x1 day
Context is girlfriend with strep

So Yes in my opinion you would count this as four. I dont think its stretching it.

Kelsey, CPC

You may have just shortened it to save time, but I just wanted to point out that your chief complaint may be shared with the HPI, so you don't have to dissect the statement further to isolate the CC.

I don't necessarily agree with the way that either of you credited the HPI elements, though...I would have credited it as:
Throat pain. CC and HPI location - the symptom is pain, and it's located in the throat.
pt c/o sore throat HPI Quality A characteristic description of the pain
x 1 day. HPI Duration The overall amount of time the symptom has persisted.
girlfriend w / recent + strep HPI Context A specific incidence or action that coincides with the symptom.

An associated sign or symptom would be something like fever, post-nasal drainage, fatigue, etc. (Problems that are other indicators of illnesses that cause a sore throat; they are not separate from and unrelated to the sore throat.) 'Sore throat' is not an associated sign/symptom - it is the symptom that's the chief complaint. Since it describes the kind of pain the patient is experiencing, it's a better fit with Quality.

Timing can be tricky - when you hear timing, think 'frequency'. Has the patient experienced this symptom constantly through the duration of their illness/problem, or does it bother them off and on? How often the symptom occurs, and for how long at each instance, is timing. Duration is the amount of time from the very first sign or symptom, to present.

Be cautious though; no matter how much HPI you squeeze out of this, it's probably still not going to qualify for a level 4 or 5 E/M, just based on the fact: that the nature of the presenting problem is mild, and is not posing a serious threat to the patient's life or bodily functions. It wouldn't be medically necessary to code the encounter as a level 4 or 5 (which both require 4+ HPI), if the patient's problem only required a level 3 (or lower) assessment. Check the clinical examples in Appendix C of your CPT book for examples.

Hope that helps!