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General Surgery Coding Alert

Reader Question:

Decide HPI Level Based on Element Number

Question: A patient came to the surgeon's office complaining of severe abdominal pain. The surgeon had performed two previous hernia repairs for the patient. The patient says the pain is occurring mostly in her umbilical and upper epigastric areas. Notes indicate that the sharp and nonradiating pains have been occurring "off and on" for two or three days; further the pains are getting worse each day. The notes also read that the pain gets worse when she sits up, but she reports no nausea or vomiting. What level history of present illness (HPI) is this encounter?Tennessee SubscriberAnswer: This is an extended HPI, as the physician noted seven HPI elements:Location (pain in upper epigastric, umbilical areas)Duration (pain has gone on for two or three days)Severity (pain gets worse each day)Timing (pain occurs "off and on")Quality (pain is sharp, non-radiating)Modifying factors (pain increases in seated position)Associated signs and symptoms (patient experiences no nausea [...]

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