Can a problem found on exam be documented as a chief complaint?

[CatchTheWind]

Pt is seen for problem A, and it's documented as the chief complaint. During the exam, provider finds problem B, and describes its location and quality. Can that be added as a second chief complaint, and the location and quality noted under HPI?

 

[thomas7331]

I don't know of any official guidelines regarding this situation. I personally would not consider it a part of the chief complaint (because that problem is not part of the reason for the visit), but I do think you can count it a part of the history. The physician is still performing a history of the problem that would found, so it's legitimate to give credit as part of the provider's work even if not related to the chief complaint.

 

[mitchellde]

Since HPI is related by the patient as is cheif complaint it could not be part of either the cc or the HPI. It is an incidental finding found by the provider during the examination. It is definitely part of the exam and a dx that will be coded but as far counting it towards the history part of the E&M I say no as it is not a part of the patient history up to this point. It is however part off the exam and the MDM.

 

[dorinda05]

I agree with Debra. Only count is towards the EXAM, it was found during the EXAM so it's not HISTORY.


Dorinda Conner, CPC

 

[cldavenport]

I agree with Debra. That was a great explanation! That's the same thing that came to mind when I read the question.

 

[thomas7331]

Yes, I'd agree if the location and quality is the description that the provider is giving based on his or her own objective examination, that is part of the exam. But if the provider is asking the patient to give additional information about the problem that the provider has identified during the exam, then it would be history. Providers will often identify something in the exam and need to take additional history (e.g. asking how long it has been there, is it painful, etc.). Since that is subjective information related by the patient, it's history and not exam by definition. As with anything, it depends on how it is documented.

 

[stephanie.moore@wdhospital.com]

As Thomas has explained and said so well. It really depends on the documentation. As all the responses that have been given are good information, however what it really depends on is the documentation. It is always helpful when asking these types of questions to de-identify and post the documentation. That way it leaves less room for misinterpretation.