Location "credit" in HPI?

jllgood

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Does anyone have a documented statement about giving credit or not giving credit for "assumed" locations in the HPI?

For example, do you give credit for location for things like atrial fibrillation, Hepatitis, etc?

I saw a string where people were discussing heartburn, and everyone gave location credit for that.

Thoughts?
 
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Hi,
In HPI for hepatitis, credit for location can be given- but not for atrial fibrillation or even heart burn.
 
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I disagree about the way location is being used and would not give HPI credit for location for any of those items you mentioned. Heartburn is arguable, but I'd prefer midsternal, epigastric or something more specific from my providers to eliminate the argument.

Location is a description of specific place(s) on the patient's body where the symptom(s) are experienced. This can include a drawing with the location marked, but does not refer to conditions such as hepatitis or atrial fib. I'd say if those are "chronic" conditions and it's all you have for HPI, that I would use the "status of chronic conditions" option for HPI documentation as allowed by the 97 DGs.

http://www.aafp.org/fpm/20030200/coding.html

Aren't we taught as coders never to "assume"? :D

Does anyone have a documented statement about giving credit or not giving credit for "assumed" locations in the HPI?

For example, do you give credit for location for things like atrial fibrillation, Hepatitis, etc?

I saw a string where people were discussing heartburn, and everyone gave location credit for that.

Thoughts?
 
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