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
