Wiki chief complaint

[Petlorilea]

My project today is to go through the January 'hold' bucket; to find out if the coding staff is having a pattern of issues with providers. What I am actually finding is that one coder is continually querying providers for their assessment not matching their HPIs. I am absolutely 100% behind them if the provider documents a chief complaint and then does not document their assessment of this complaint.
However....I am coming unhinged over the fact that the provider is being OVER queried (in my opinion - that's where you all come in) for the reverse. For example chief complaint is vaginal discharge and DM. In the exam, the provider finds a breast mass. In the assessment, the provider addresses the discharge, DM management and breast mass (she has ordered mammo). The coder wants the provider to amend the HPI to include breast mass. I do not agree. If this is the case, then I should probably let my CPC lapse and forego the ICD10 training, because this makes no sense to me.
Thoughts?

 

[mitchellde]

you are correct. The breast mass could not be in the HPI since it was found upon examination. This happens all the time. The HPI is based on what the patient feels is the issue, in this case the patient could not utter a complaint or issue regardin a breast mass she had no idea was there.

 

[erjones147]

Agree with DAM. You should keep your CPC and maybe ask the coder to review the definition of HPI/patient history so they can keep their own credentials

 

[Petlorilea]

Thank you for restoring faith in my (hard earned) framed certificate. My scalp thanks you too.....a few of these coders nearly make me tear my hair out!