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What's your opinion?

  1. #1
    Default What's your opinion?
    Clearnace Sale
    When you are auditing an E/M visit and you are looking at the details of the HPI - can location be assumed? If the dx is "heartburn," doesn't that infer the location? Or would the physician need to specify where the heartburn is located.

    I realize that you need 4 or more details to reach a level 4 or comprehensive HPI. And, as you know, the details of the HPI are:

    location, quality, severity, timing, duration, context, modifing factors, associated signs and symptoms.

    I have an HPI that has documentation of duration (present since 2/08) modifying factors (taking Tums) and context (symptoms disappeared while on vacation and free of stress). Can I give credit for documenting the location, since Heartburn can only be located in one area?

  2. Default
    Heartburn can be used as an associate sign and symptom since it is a symptom of GERD.

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