• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki E/m diagnosis

Create Wiki
S

sluke9

Guest
Messages
52
Location
Columbus, OH
Best answers
0
A physician is using the HPI & PMH as the basis for current visit diagnosis of asthma exacerbation. The exam is benign for any current breathing problems. Chest exam states that the chest is clear, no resp distress. If there isn't any current breathing problems, I say they can't they use HPI & PMH as sole reason for dx. Does anyone know of documentation guidelines to support this or am I wrong in my thinking?
Thanks for any help!!
 
The Chief Complaint is what sets the tone for the visit The HPI is to further explain the CC and the PMI is history. The exam is what the provider sees, finds, discovers which is where the dx is made. You could not code Asthma exacerbation with what you have stated as the exam
 
You must log in or register to reply here.
Top