I recently had the opportunity to review another coder’s work and was shocked at the differences in my findings versus hers so I thought I would get comments on what others thought about a couple of the scenarios.

Scenario 1:

A patient was referred to a urologist with an elevated PSA.  I took that as the chief complaint.  The urologist then went through the chronology of the patient’s PSA’s describing the steady increase over the past three years.  The initial value was 2.0 ng/mL, then went to 2.5 ng/mL.  The patient didn’t have it checked for over a 1 year period and then the value was 4.3ng/mL.  At that point his primary care physician referred him to the urologist.

I took this information to be the elements of the HPI; not part of the review of lab results that is encompassed in medical decision making and came up with the following:
  • The level of the PSA (4.3 ng/mL) – severity of the problem; (Normal value is <2.5 ng/mL)
  • location is prostate,
  • duration is the past two years
  • steadily increasing – quality
I didn’t put it to medical decision making and would anxious to hear others thoughts.

Scenario 2:

A 64 year old female is referred to a hematologist with a steadily decreasing hemoglobin over the past 6 months.  The patient’s hemoglobin has gone from 12.1, to 10.5 to 8.7 and then to 6.4.  The patient underwent numerous endoscopic and other blood studies to identify any potential source of bleeding, yet the hemoglobin continued to decline.  When the patient’s hemoglobin went to 6.4, the patient received 2 units of blood to bring the hemoglobin to 8.0.

This scenario, like in Scenario 1 met the criteria for an extended HPI.

Anxious to hear from others on this.  Georgeann