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Coding from HPI or Chief Complaint?

  1. Default Coding from HPI or Chief Complaint?
    Medical Coding Books
    If there is a diagnosis listed in the chief complaint or HPI and addressed somewhere within the note, but not mentioned anywhere within the Assessment or Plan, is it okay to code for that diagnosis? I believe this is reasonable but just wanted to double check...

  2. #2
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    Quote Originally Posted by amarie234 View Post
    If there is a diagnosis listed in the chief complaint or HPI and addressed somewhere within the note, but not mentioned anywhere within the Assessment or Plan, is it okay to code for that diagnosis? I believe this is reasonable but just wanted to double check...
    It depends. If a symptom is mention in the cc or HPI and it is determined that there is an underlying diagnosis responsible for this symptom the no you do not code the symptom. If the dx mentioned and referenced in the note is a dx that complicates the management of the patient then you would code it.
    Do you have an example of one that you are concerned about?

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    You may use the CC/HPI to report any documented sign/symptom documented by the provider if it is not a part of the disease process. The key part is ensuring it is addressed by the provider.

    You may also use the chief complaint/HPI to supplement the diagnosis in the assessment. For example if the patient presents w/abdominal pain and the physician documents the pain in the RLQ but only notes abdominal pain in the Assessment part of the record, you should report RLQ abdominal pain.

    Doris

  4. Default
    Thanks!

    For example,

    In an office visit for a physical exam, "Subjective...Depression: controlled on Zoloft, no side effects." But then not listed or addressed in the Assessment or Plan. Can I code this?

  5. #5
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    Is the depression the reason for the encounter? Is it a part of the exam? If no then it should not be coded.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    It's a physical exam and the provider is listing and addressing a number of diagnoses in the Subjective portion of the note only.

  7. #7
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    Does anyone have a good resourse that discusses this? I am having a really hard time getting our physicians to understand that when the HPI and the assessment say two different things, that is a problem.

    Example:

    HPI: Patient has controlled type two diabetes complicated by peripherial neuropathy.

    Assessment: 250.02 Diabetes, uncontrolled without complications

    To me this is a problem, but they aren't understanding it. Any help?

  8. #8
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    Yes, how can it be "...uncontrolled without complications" when in the history it's complicated by peripheral neuropathy? And it's also controlled in the history as well. Odd very odd.

    Something is definitely not right there.

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