tci ED Coding & Reimbursement Alert - 2011 Issue 5

Reader Questions: Spot Extended HPI for Higher-Level E/Ms

Question:A teenager presents with intermittent right sided abdominal pain occurring at least three times per day mostly in the morning for the last week with associated nausea and vomiting. Both parents of the teenager have had their appendixes removed. The patient rates the current pain as eight out of 10, and says it is a sharp, stabbing pain unrelieved by Tylenol. The ED physician performs a physical examination, including a detailed examination of the gastrointestinal system and other related systems including, constitutional, cardiovascular, respiratory, and genitourinary. The physician cannot determine the etiology of the abdominal pain, so the patient...

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