If there is a diagnosis listed in the chief complaint or HPI and addressed somewhere within the note, but not mentioned anywhere within the Assessment or Plan, is it okay to code for that diagnosis? I believe this is reasonable but just wanted to double check...
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Wiki Coding from HPI or Chief Complaint?
- Thread starter amarie234
- Start date
mitchellde
True Blue
It depends. If a symptom is mention in the cc or HPI and it is determined that there is an underlying diagnosis responsible for this symptom the no you do not code the symptom. If the dx mentioned and referenced in the note is a dx that complicates the management of the patient then you would code it.
Do you have an example of one that you are concerned about?
dbranker
Networker
You may use the CC/HPI to report any documented sign/symptom documented by the provider if it is not a part of the disease process. The key part is ensuring it is addressed by the provider.
You may also use the chief complaint/HPI to supplement the diagnosis in the assessment. For example if the patient presents w/abdominal pain and the physician documents the pain in the RLQ but only notes abdominal pain in the Assessment part of the record, you should report RLQ abdominal pain.
Doris
You may also use the chief complaint/HPI to supplement the diagnosis in the assessment. For example if the patient presents w/abdominal pain and the physician documents the pain in the RLQ but only notes abdominal pain in the Assessment part of the record, you should report RLQ abdominal pain.
Doris
mitchellde
True Blue
Is the depression the reason for the encounter? Is it a part of the exam? If no then it should not be coded.
coder2533
Guest
Does anyone have a good resourse that discusses this? I am having a really hard time getting our physicians to understand that when the HPI and the assessment say two different things, that is a problem.
Example:
HPI: Patient has controlled type two diabetes complicated by peripherial neuropathy.
Assessment: 250.02 Diabetes, uncontrolled without complications
To me this is a problem, but they aren't understanding it. Any help?
Example:
HPI: Patient has controlled type two diabetes complicated by peripherial neuropathy.
Assessment: 250.02 Diabetes, uncontrolled without complications
To me this is a problem, but they aren't understanding it. Any help?
BenCrocker
Guest
Yes, how can it be "...uncontrolled without complications" when in the history it's complicated by peripheral neuropathy? And it's also controlled in the history as well. Odd very odd.
Something is definitely not right there.
Something is definitely not right there.