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Do you get 4 or is it too much of a stretch?

R

renifejn

Guru
Messages
208
Location
Bolingbrook, IL
Do you get 4 HPI elements here or do you think it may be too much of a stretch?

CC Asymptomatic heart murmur
A heart murmur was noticed at a routine physical exam. There is no hx of tachypnea, cyanosis or syncope.

loc-heart
quality-asymptomatic
timing-at a routine physical exam
s/s--no tachypnea
 
I would not use " no tachypnea" as asso/s/s. According to the Lunchtime EM coding seminar I have been listening to by WPS Medicare, you should not use the negative for a/s/s. You should use the tachypnea in the ROS.
 
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