Bonnie Posted Tue 06th of January, 2015 14:08:26 PM
Hi:An MD see new patient with chief complaint stated as "new patient evaluation". Patient presents with gait instability and back pain. Under 1995 EM guidelines can the total HPI elements be captured for both the gait instability and back pain or just for one of these diagnosis. Guidance states that HPI elements are related to the chief complaint, however in this situation the chief complaint is not definitive. Thanks so much!
SuperCoder Answered Tue 06th of January, 2015 17:05:54 PM
Thank you for your question.
You are correct. The gait instability and back pain may both be used for HPI. Often times the CC (Chief Complaint) is entered by someone other than the provider treating the patient. In this case, count the HPI elements and if possible, provide education to the clinical staff that they should be reviewing and updating the CC to reflect the true reason for the visit.