If the physician dictates, “the patient presents with a headache that he has had for two days”, can we count both the Chief Complaint and the HPI element of location using this one statement?
Per WPS Medicare Part B, “If the chief complaint is headache the location of the HPI would be the head. (The two are very similar.) The remainder of the HPI elements would clarify the concern of the headache. The Chief Complaint and the HPI support each other, however, the same element cannot be assigned to both (HPI and ROS).
Related Questions
- If the physician dictates, "the patient presents with a headache that he has had for two days", can we count both the Chief Complaint and the HPI element of location using this one statement?
- If an obstetric patient presents to the hospital with an obstetric related complaint, what is the role of the registered nurse in performing a nursing assessment?
- How should I bill an exam when a patient requests a routine exam (has no chief complaint), but an eye problem is discovered?
