Quote Originally Posted by Mojo View Post
This article addresses the E/M gray areas:

◦Documentation counted toward elements of HPI must relate to the chief complaint (except associated signs and symptoms). If the patient presents with multiple complaints, the coder may choose which one to consider the “chief” complaint and other problems may be counted as associated signs and symptoms, elements of ROS, or past medical history. The problem chosen should be the one that provides the documenter with the most complete HPI.
■Example: A patient presents with arm pain from an accident and also complaints of arm numbness off and on. This counts as location (arm), context (accident), and associated signs and symptoms (numbness) but not timing (off and on) (off and on refers to timing related to the numbness, not the arm pain).
◦A completely unrelated condition or symptom may not be considered an associated sign or symptom but if the coder is not certain whether the condition may be related the clinician should be given credit for the documentation.

Definately some good points in this article...

I thank you as well