History of Present Illness

 Severity Severity –moderate chest pain 6 out of moderate moderate chest pain, 6 out of 10 

 Duration-10 minutes, for a week 10 minutes, for a week 

 Modifying Factors–worse with exertion, worse with exertion, unrelieved by Tylenol 26 unrelieved by Tylenol 

 Associated Signs and Symptoms diaphoresis, fever, vomiting

 HPI flushes out the chief complaint in greater detail 

 There are two types of HPI identified for the purpose of coding 

 A brief HPI consists of HPI consists of 1-3 elements elements (99281-99283) 

 An extended HPI consists of at least HPI consists of at least 4 elements elements (99284-99285)

HPI Examples

 Brief- 32 year old male with 32 year old male with left shoulder left shoulder injury, occurred 4 hours ago

 Extended Extended-45 year old female with 45 year old female with left sided, sharp chest pain for 30 minutes with left arm numbness and diaphoresis 28 with left arm numbness numbness and diaphoresis  The pain is worse with exertion

Multiple Modifying Elements

Child with Chief Complaint of fever: Child with Chief Complaint Complaint of fever: 4 hours 4 hours of fever, with of fever, with moderate vomiting moderate vomiting, diaphoresis that is worse at night diaphoresis that is worse at night, right lower quadrant abdominal pain lower quadrant abdominal pain, unrelieved unrelieved by Tylenol

Review of Systems (ROS)

 An inventory of body systems An inventory inventory of body systems systems 

 “Patient’s positive responses and pertinent negatives should be documented”

 “For the remaining systems, a notation indicating all other systems are negative is 30 indicating indicating all other systems systems are negative negative is permissible”