Wiki H & P physical exam

[stephh1982]

Is it appropriate to code from the physical exam on the H & P? For example if the physician documents abdomen: obese can you code obesity from this?

 

[mitchellde]

the question is why? You code only the reason for the encounter, plus any other diagnosis that are managed, controlled , or treated , or any condition that complicates the management of the presenting issue.

 

[cpccoder2008]

I have the same question regarding inpatient stays. If a patient is admitted and on the H&P under the physical examination it states- Obesity or Obese Male/Female with elevated BMI and they have a documented BMI of more than 40 can we pick that code up ? I'm being questioned for an audit review on why I picked up obesity.

Thanks

 

[erjones147]

There's no rule that I'm aware of that says you can't pick up a Dx from the exam; however, just because the subjective or objective mentions things like "obese body habitus" or "lifelong smoker" doesn't mean you should just start throwing obesity or tobacco use disorder onto every visit

You CAN add them to the problem list as a provider's choice for future encounters