Vaida Posted Mon 14th of October, 2013 15:16:43 PM
Hi. If patient comes to the office for biopsy follow, does stating "Modifying factors include biopsy" give you a credit for Modifying factors as an HPI factor? Can you please give me a better idea what modifying factors mean? My understanding was that modifying factors are things that make pain and symptoms worse or better, but our medical provider here in the office is trying to convince me that it's also the procedures, prescriptions etc used for this problem...
Clarification on this issue would be greatly appreciated. Thank you in advance!
SuperCoder Answered Tue 15th of October, 2013 08:24:09 AM
You are correct. Modifying factors are things that make pain and symptoms worse or better. For example, if HPI states that "pain eases with taking XYZ tablet". This is a "modifying factor" statement. But as per this sentence, "biopsy" is not a modifying factor.
Prescriptions could be modifying factor, but then the HPI needs to be clear on what better/worse did that do. For example, "...per last prescription, 25mg of paracetamol relieved the evening-fever within 2 days."