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Chief Complaint- double dipping?

  1. #1
    Default Chief Complaint- double dipping?
    Medical Coding Books
    If you pull the chief complaint from the body of the HPI, can the info be used again toward the HPI elements? e.g. Patients presents with complaint of low back pain. Has been present for 3 days, radiates down his leg.
    Can the low back pain be used for the chief complaint AND as location under the HPI? Or is this considered double dipping?

    I understand that the same dictation may be used to give credit in the HPI and ROS without it being considered double dipping but does this hold true between the CC and the HPI? THanks!

  2. #2
    Default Nope
    The Chief Complaint and HPI can be shared. Only the ROS and HPI have to be counted separately.

  3. #3
    I have to disagree with you on that Brandi.

    Chief complaint is stand alone. If you pull from your HPI to get a chief complaint, you can't use that as an HPI element anymore.

    Laura, CPC, CPMA, CEMC

  4. #4
    Thanks for the responses-
    According to info I've seen about the double dipping "urban legand" on the ER Coder Web site, I believe that the HPI and ROS can have the elements used for both with out redocumenting the information but wasn't sure about the chief complaint. Thanks again for the help.
    Laura, do you have a resource where your answer has been pulled from?

  5. Default


    Q 22. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).
    A 22. Yes. According to the E/M 1995 and 1997 DG, "The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness
    Jagadish, CCS-P, CPC

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