The Basics
Elements
Break the Bill Code
The Chief Complaint
Wrapping it Up
100

Significance of the abbreviation HPI

What is history of presence illness

100

The acronym for the elements of the HPI

What is OLDCARTS?

100

Number of elements that must be included in the HPI and why

What is 4 elements, and so the provider can bill teh appropriate level of service?

100
Name 4 "vague" chief complaints that should never be the only chief complaint/reason for visit
What is Follow Up, Medication Review, Lab review, establish care
100

Rationale for documenting important pertinent positive and negatives of the ROS

What is to ensure that the provider has covered all of the patients concerns during the visit and that nothing is missed?

200

Typical timeline for the HPI

What is from the last time we saw the patient, until the present visit

200
How many elements MUST be covered for each chief complaint?
What is 4
200

Result of information in the assessment and plan but not in the HPI?

What is the provider cannot bill based on it?

200
After you complete the HPI and ROS and tell the provider about the patient, do you add to the HPI or is it now considered complete?
What is Yes - you add anything that the patient mentions while the provider is talking with the patient into the HPI
200
What does the C stand for in OLDCARTS? What does it mean?
What is Characteristics, and it has to do with the descripting factor (i.e. aching, burning, dull)
300

Does the HPI include subjective or objective data? what is the definition of both of these?

What is subjective - subjective is something that is not measurable or tangible, it is what the patients says and reports. Objective is something that can be measured, it is the providers physical exam

300

Name 5 of 8 elements of the HPI

What is location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms. Onset, location, duration, characteristics, aggravates, relieves, timing, severity?

300

Code given to most patients presenting to primary care

99213  (or 99214 if they have 2+ chronic conditions)

300
If a patient comes in with the chief complaint of Hypertension, what are pertinent ROS questions you would, and what element of the HPI does that cover?
What is anxiety, blurred vision, headaches, neck pain, palpitations, edema, shortness of breath, sweating. Associated signs and systems. 4 Systems covered with one HPI asking questions and documented positive and/or pertinent negative
300
If you have a chief complaint in the HPI, where else should we be addressing the chief complaint?
What is Assessment and Plan
400

Tool you should use for your SOAP note?

What is a template?

400

Name the parts included in the "S" of the SOAP note.

What is CC, HPI, PMH, PSH, SH, FMH and ROS?

400

Number of systems in the ROS that need to be reviewed to code a 99215

What is 10?

400
Can the Chief Complaint be left blank if the patient doesn’t know why they are being seen?
What is No. Look at the patient’s last CN and/or telephone calls to see why the patient was asked to come in for an appt.
400
What is a pertinent Negative?
What is An element of the patient's history that aids diagnosis because the patient denies that it is present.
500

Additional location of information located in the Assessment and Plan

What is in the HPI?

500

Method of including unique patient statements in the HPI

What is quotations or "patient states"?

500

Code used for a non-complex (self-limiting problem) new patient visit

What is a 99201?

500
On average, how many CC can be covered in an “established, follow up” appt.
What is No more than 3 (unless the provider states otherwise) It’s perfectly acceptable to let that patient know there is a possibility of another appt scheduled to review their additional concerns. (“Dr. X would love to go over everything with you today but their schedule today doesn’t allow that long of a visit. Is it ok with you if we discuss the top 3 concerns you have and then schedule you a follow up appt in 2 weeks?”)
500
What 3 sections of the chart note need to match for proper billing/coding
What is HPI, ROS and Assessment and Plan
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