Context and modifying factors are two separate elements of the HPI. Context is what was happening when the issue was first noticed or how the problem has manifested since onset. It is a description that paints a bigger picture of what has been or is going on with that problem. It also can be a description of the course of treatment that the ...
Remember that factors present before or after the problem can support context as well. HPI should include symptoms the patient is experiencing due to his or her chief complaint. Therefore, we commonly note that negative findings in the HPI are truly ROS and not HPI, but there is an exception to this: no known injury or accident.
The History of Present Illness (HPI) is used to describe the status of the symptoms or clinical problems from time of onset or since the previous encounter with the physician. Some form of HPI is required for each level of care for every type of E/M encounter. For follow-up visits, it is acceptable to call the HPI an “Interval History.”
HPI is easier to understand using examples because there are a lot of nuances in the dif-ferent elements. Some, such as location and severity, are fairly straightforward. Others, such as timing and context, can be more dif-ficult to spot. See if you can correctly identify the HPI in these examples: Example A: Patient presents with nausea,
An extended HPI consists of four or more elements. The example "Patient present with lacerated right finger (location) while cutting fruit (context) that happened this a.m. (duration.) She stated the laceration bled a lot (severity) and continued to bleed after wrapping it tightly with gauze (modifying factors)" meets five elements.
The history of present illness (HPI) is a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms significantly related to the ...
HPI Patient and father report increasing (timing), moderate (severity) sadness (quality) that seems to be present only at home (context) (duration).and tends to be associated with yelling and punching the walls (associated signs and symptoms) (timing)at greater frequency, at least once per week when patient frustrated. Anxiety has been ...
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The HPI is brief if one to three elements are documented and extended if four to eight elements are documented. CPT codes 99204, 99205, 99214 and 99215 all require an extended HPI. Negative responses count when they are pertinent to the chief complaint, such as in the example of growths below.
CPT Coding and E/M Documentation Training Resources Background Material • E/M Services Guide-AACAP • E/M Coding Review • Examples for Evaluation and Management Codes-AACAP • Counseling and Coordination of Care E/M Progress Note • Templates, Outpatient & Inpatient-Stein, S.P. • Outpatient E/M Progress Note Template-Based on the Elements • Selected Sections from the CPT Primer for ...