Which element did the auditor question? Obesity? Probably not medically considered a location.
I also don't believe counting weight loss programs as a modifying factor would be an HPI element; although "unsuccessful," how was they obesity "modified?" Did they cause additional weight gain or possibly only slight weight loss which the patient didn't consider fast enough and therefore unsuccessful... If the physician had added this comment, I'd be more likely to count it. I do realize, however, the credit was probably allowed just for stating "unsuccessful." I'd have been more comfortable with a statement of causing extreme exhausting or SOB with activity, therefore negating exercise.
Also, the doctor mentioned 4 chronic illnesses associated with the diagnosis of diabetes; sleep apnea, diabetes, hypertension and arthritis, If the physician had only mentioned if these were stable or worsening, I'd allow credit for mentioning the status of "three chronic or inactive problems..." under the '97 guidelines thus allowing an extended HPI without question.
Once again what should be black and white just isn't. Having stated my opinion above if I felt strongly obesity was a location I'd fight for it as being a logical location of the body in general!
Hopefully the answer was arrived at in the review of medical decision making. Since the obesity is not worsening, without justification for moderate or high decision making, you likely won't qualify for more than a problem focused hx and exam, and end up back at a brief HPI anyway.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join