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Difficultly Breathing as location

  1. #1
    Default Difficultly Breathing as location
    Medical Coding Books
    If the patient presents to the ED and the CC is difficulty breathing, can that be counted as location? There is no mention of chest pain/cough, etc. Only difficulty breathing, pain 9/10 and started yesterday at 7pm.

  2. #2
    Location
    Kingsport, TN
    Posts
    149
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    You state pain 9/10, where was the pain? That would be your location.

  3. #3
    Default
    I would say difficult breathing would be under severity

  4. #4
    Default Difficulty Breathing
    If the physician is using difficulty breathing as the chief complaint, then it cannot be used again in the HPI. This was talked about at an E/M Coding seminar about a month ago.
    Tiffany Fischer, CPC, CEMC

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
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    Quote Originally Posted by tfischer View Post
    If the physician is using difficulty breathing as the chief complaint, then it cannot be used again in the HPI. This was talked about at an E/M Coding seminar about a month ago.
    What seminar was that and by whom? If the CC "difficulty breathing" is written by the nurse it is not countable in the HPI, but if the physician states it, it is countable. This also appears to be a quality to me.
    Lisa Bledsoe, CPC, CPMA

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