dballard2004
True Blue
A co-worker of mine who is also an auditor brought up a very interesting question that I would like others opinion on please. If the provider documents the following:
CC: Ear pain
HPI: Ear pain for three days
In this above scenario, would you count ear pain as the location element of the HPI? My co-worker attended an auditing class this past week where they said that unless the provider specifically states something to the effect of "left ear pain, " it does not count as location but as associted signs and symptoms.
To me the above would be location because you are stating that the pain is in the ear, but I do see the other side as well because you are not stating exactly where the pain is without elaborating further.
Any thoughts?
CC: Ear pain
HPI: Ear pain for three days
In this above scenario, would you count ear pain as the location element of the HPI? My co-worker attended an auditing class this past week where they said that unless the provider specifically states something to the effect of "left ear pain, " it does not count as location but as associted signs and symptoms.
To me the above would be location because you are stating that the pain is in the ear, but I do see the other side as well because you are not stating exactly where the pain is without elaborating further.
Any thoughts?
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