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HPI conflict with Diagnosis

  1. Question HPI conflict with Diagnosis
    Medical Coding Books
    Please advise me if I am wrong.

    The physician noted in the HPI skin tag, but the diagnosis and in the procedure it was noted wart.

    When auditing the encounter prior to finalization I queried the doctor on the HPI. The physician stated "that is what the patient said". I responded that I just wanted clarification so that I could make sure the correct procedure was inserted for billing purposes.

    My question is am I correct that the chief complaint is what the patient thinks is wrong or dx. The HPI is the the physicians description meeting the standards with location, duration, quality etc.

    Was I wrong to query the physician?

    Thank you for your time and help in advance.

  2. #2
    Default
    The chief complaint is what the patient is presenting to the office for and often will be in their own words. The chief complaint must be documented by the physician or mid level provider. The HPI is a subjective account of what has been going on (the patient's summary of what has been bothering them). the physical exam will be the physician's exam of the patient and confirmation of complaints in the HPI.

    It is ok for a patient to state "I have a skin tag" and the physician actually diagnosis it as a wart by the end of the visit. You would also credit the integumentary/skin section of the ROS under that scenario

    Good Luck!
    Martinni

  3. Default
    You asked if you were wrong to query the physician. NO. Any time you are uncomfortable with what the doctor meant, you need to ask...with that said, just because a patient states their 'view' of what is wrong does not mean it is the diagnosis. It is mearly the starting point for the physician to work with the patient in determining the diagnosis. An example would be a patient that comes in and says they are there because they have strep throat, but through exam the patient has an upper respiratory infection. You would code the physician's outcome and not the patients view. With that in mind remember that what you code and file with insurance stays on their medical history with the insurance. An incorrect diagnosis can plague a patient in the future if they are trying to change insurances.

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