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Posted By mary peabody on 05-19-2019, 18:20:18 in Ob-Gyn
I am coding Oncology Visit and trying to determine what would be the HPI for a follow up visit for cancer. Would you get four HPI based on these elements? HPI: Location-rectal, Severity-Stage 1, Duration-1/19/2017, Modifying factors-RA LAR, low pelvic colorectal anastomosis (or is this consider past history and the HPI should be taken only from the interval history) ? Most of the oncology notes always include the history of the cancer, when determining the history of present illness, should the coder only pull HPI from the interval history?

_____ 50 y.o. female with Stage I Rectal Cancer
Rectal cancer
Cancer Staging
H/o rectal cancer s/p RA LAR, low pelvic colorectal anastomosis,and diverting loop ileostomy followed by takedown c/b SBO
Staging form: Colon and Rectum, AJCC 7th Edition
- Clinical stage from 1/19/2017: Stage IIA (rT3, N0, M0) - MD on 1/19/2017
- Pathologic: Stage I (T2, N0, cM0) -

ONCOLOGIC HISTORY:
She initially presented late 2015 with a three-year history of progressive hematochezia.
11/19/16: Sigmoidoscopy was performed revealing a large rectal polyp 3-4 cm from the anal verge.
A colonoscopy on 12/10/16 again revealed a large rectal polyp,which was removed, along with a small polyp in the ascending colon. Pathology revealed a well-differentiated invasive adenocarcinoma invading into superficial submucosa. The resection margin was negative (<1mm). The ascending colon polyp was found to be a tubular adenoma.

12/21/16: A CT scan of the abdomen/pelvisshowed diffuse thickening of the rectum without discrete mass, and no lymphadenopathy. She saw Dr. ____12/21/16 at which time proctoscopy revealed a pedunculated polyp with a wide base on the right lateral wall, with the inferior margin 9-11 cm from the anal verge. She recommended further workup with MRI to determine whether she would be a candidate for transanal resection.

1/6/17, an MRI of the pelvis revealed a 2.5 x 2.0 x 1.5 cm enhancing mass along the right margin of the superior rectum, with the inferior edge approximately 9cm from the anal verge, involving up to 30% rectal wall circumference. The tumor extended 13 mm beyond the muscularis propria. There were no suspicious lymph nodes. Based on the MRI, the tumor was radiographically staged as cT3cN0.

1/20/17 CT chest without contrast showed a single 6 mm noncalcified nodule in the right upper lobe which is favored to represent sequela of prior granulomatous disease, although metastasis is not excluded.


2/16/17: Robotic low anterior resection with takedown of
splenic flexure, creation of low pelvic colorectal anastomosis and
diverting loop ileostomy.
Path: pT2N0



INTERVAL HISTORY
Patient presents today to follow up in GI Survivorship clinic
Bowels have improved with acupuncture but still having BM's after eating
Good appetite


REVIEW OF SYSTEMS:
Systemic: Negative for fevers, chills, or sweats. Weight, appetite, and energy are stable.
Cardiac: Negative for chest pain or palpitations.
Respiratory: Negative for shortness of breath, dyspnea, or cough.
Abdominal: Negative for distension, pain, nausea, vomiting, or diarrhea. No melena or BRBPR.
Skin: Negative for rash or jaundice.
Musculoskeletal: Negative for bone pain or swelling.
Neurologic: Negative for neuropathy, headaches, blurred vision, or confusion.
Hematologic: Negative for bruising or bleeding.
Psychiatric: Mood is stable. Patient denies symptoms of anxiety or depression.
All other systems were reviewed and are negative.
Comments (1)
Posted By Melanie Witt on 05-22-2019, 15:00:20
The first thing that you have to know is why she is being seen. The HPI relates to the reason for the visit, not a history of cancer. And would a gyn oncologist be treating a patient will rectal cancer in the first place? The note says she is here in folow-up to GI clinic, but what does that mean? Was an exam done, was the patient mainly counseled? Is she being seen as a follow-up to surgery? All of these issues must be addressed first. If this is truly just a follow-up visit and the patient has no complaints, the HPI would be the elements mentioned in the interval history above. Location (bowl), modifying factor (acupuncture), context (after eating).
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