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Do you get 4 or is it too much of a stretch?

  1. Default Do you get 4 or is it too much of a stretch?
    Medical Coding Books
    Do you get 4 HPI elements here or do you think it may be too much of a stretch?

    CC Asymptomatic heart murmur
    A heart murmur was noticed at a routine physical exam. There is no hx of tachypnea, cyanosis or syncope.

    timing-at a routine physical exam
    s/s--no tachypnea

  2. #2
    I would not use " no tachypnea" as asso/s/s. According to the Lunchtime EM coding seminar I have been listening to by WPS Medicare, you should not use the negative for a/s/s. You should use the tachypnea in the ROS.

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