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Wiki Does it have to be in the HPI to be counted

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melmontgomery

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Paducah, KY
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Scenario: A patient is being seen in a dermatology office for a wart on their ear. The provider has completed a ROS including the integumentary system and a full body physical exam. Incidentally they notice a nevi on the patients face. Since the nevi was not a part of the HPI but was a part of the Assessment can it be included in the MDM or would the provider have to amend the note to include it in the HPI? Basically my question is does every dx in the assessment have to be noted in the HPI?
 
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Hi there, history and exam aren't used to determine MDM in the office (and won't be in other settings next year). What matters is that the documentation must show the doctor addressed the additional problem.
 
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