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Click here for more sample CPC practice exam questions and answers with full rationale

HPI Element

How many elements do you see:

Ms. Smith is a 55 year old female with nausea and vomiting and I was consulted by (Doctor) for assisting with further management. She has been having nausea and vomiting since Monday and not able to keep anything down. She has a history of acid reflux on medication for that every other day. Denies of abd pn. She is on laxatives for constipation but still struggles to have bowl movement. Denies of diarrhea. She had left BKA 2 years ago for diabetes. she is also blind. History of chronic kidney disease on dialysis. she is morbid obese with BMI 41 and is bedridden.

Medical Billing and Coding Forum

Physical Exam Element Extremity?

Patients exam below

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
GU: has small epidermal cyst in left scrotum

Extremity: no edem ** Can I count this towards the MS or Skin? Or is it just rolled in with the CV?**

Thank you,

Nichole

Medical Billing and Coding Forum

HPI element : Modifying Factor

Does alleviation or aggravation of treatment tried be documented to count against Modifying factor?

Example:

Patient is a 58-year-old Caucasian female with sore throat, headache, chills and fever for past 3 days. Pain is rated as 5/10 on pain scale. Patient is experiencing dull pain. She tried lozenges yesterday.

Per my understanding, HPI elements are Duration, severity, associated symptoms and quality. Please correct me if I am wrong.

My question here is patient has tried lozenges, however, no relief is documented. Can I count this against modifying factor?

Medical Billing and Coding Forum

“moderate in severity” as HPI element

Can you count this statement (describing a skin lesion) toward the severity level in HPI? "It is moderate in severity." Or does the provider need to be more specific, like stating the size of the lesion, the pain (if any) it is causing, etc. (And if so, how do I know from a statement of the size of the lesion how severe this size is considered?)

Medical Billing and Coding Forum

E & M exam element guidelines

Have any of you heard that in July 1, 2017 exam elements are changing from 2-7 elements for Expanded problem-focused and Detailed,
or 2-4 elements for Expanded problem-focused and 5-7 for detailed to:
2-5 elements for expanded problem focused and 6-7 for detailed?
That means exam level may change from 4 to 3 if only 5 elements are used
By elements I mean a body/organ system with at least 2 points per area on body.
According to Medicare, now at least 6 body/organ systems will be necessary for a level 4 (detailed) exam
Is this right?
Are there any updated E and M audit worksheets out there to reflect new exam requirements?
thanks

Medical Billing and Coding Forum