Pulling signs/symptoms/dx from the history

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Pulling diagnosis - refer to last question

Hi all,

Need help! I am curious to find out, can you pull signs/symptoms or diagnosis from the history (Subjective portion of the visit) if it's a follow up visit? I am getting conflicting answers.

Thank you,

dscoder74
 
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ndhight

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I would say that if there isn't a diagnosis then you could the primary icd9 to be the sign or symptom. The only way you can code from history is if the reason they are seeing the patient has to do with a condition that is in the family history or is socially related. Say that patient is in b/c they felt a lump in breast and the conculsion was that it was probable for cancer and there is a family history of it then you would use the vcode. If I am wrong someone please help.
nichole
 
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History of Present Illness

The History portion of the exam include the HPI ... and ROS ...

So if your phsycian doesn't specifically dictate a separate statement of diagnosis, then, YES you can pull the signs/symptoms from the HPI or ROS to code those.

But better if you educate your doctor to always state a diagnosis.

F Tessa Bartels CPC
 

ashack63

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HPI for diagnosis

In many cases, the patient presents with signs and symptoms with a Rule Out by the doctor as their final diagnosis. As outpatient's are not allowed to use rule outs, signs and symptoms are most definately the reason for the visit.
The past history or ROS are not the reason for the visit - / Chief complaint is, which is in the HPI
 
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