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Primary Care Coding Alert

READER QUESTIONS:

Where Do You Count Forgetfulness?

Published on Fri Apr 24, 2009

Question: A patient comes in with a chief complaint of -increasing forgetfulness.- How could I apply the mini mental status exam (MMSE) into the history component's history of present illness (HPI)? Should I count it as context? Or could it be part of the E/M level's medical decision making (MDM)? Indiana Subscriber Answer: You note that -increasing forgetfulness- is the patient's chief complaint. The chief complaint isdistinct from the HPI. Documentation of the development of the patient's increasing forgetfulness, however, could be counted under HPI. Here's how: Under HPI, a statement of the condition's quality, which may be a description of discomfort, could be relevant. For example, a statement that the forgetfulness is chronic lends to the HPI. Context, on the other hand, is a description of where the patient is or what he is doing when the signs or symptoms begin. A context note could indicate the forgetfulness has [...]
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