Kedami38
New
I have a question I was coding a admission and discharge same day observation E/M and I had trouble with getting 4 elements in the HPI
Chief Complaint: shortness of breath, cough
History of present illness: 69 year old male with past medical history of hypertension, atrial fibrillation, COPD presented to emergency room was complaints of worsening shortness of breath for the last couple days. Denies any chest pain medicine nausea no vomiting. On admission in emergency room stay chest revealed bronchiectasis, scattered mucous plugging, emphysema.
I had worsening as either quality or severity, last couple days for duration and shortness of breath, chest pain for associated sign and symptoms
My auditor states that I should use shortness as quality..........I'm having trouble understand this as it is not a character of a symptom because it is actually the symptom and breath is not a symptom. My question is can this be used as quality?
Chief Complaint: shortness of breath, cough
History of present illness: 69 year old male with past medical history of hypertension, atrial fibrillation, COPD presented to emergency room was complaints of worsening shortness of breath for the last couple days. Denies any chest pain medicine nausea no vomiting. On admission in emergency room stay chest revealed bronchiectasis, scattered mucous plugging, emphysema.
I had worsening as either quality or severity, last couple days for duration and shortness of breath, chest pain for associated sign and symptoms
My auditor states that I should use shortness as quality..........I'm having trouble understand this as it is not a character of a symptom because it is actually the symptom and breath is not a symptom. My question is can this be used as quality?