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sluke9

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A physician is using the HPI & PMH as the basis for current visit diagnosis of asthma exacerbation. The exam is benign for any current breathing problems. Chest exam states that the chest is clear, no resp distress. If there isn't any current breathing problems, I say they can't they use HPI & PMH as sole reason for dx. Does anyone know of documentation guidelines to support this or am I wrong in my thinking?
Thanks for any help!!
 
The Chief Complaint is what sets the tone for the visit The HPI is to further explain the CC and the PMI is history. The exam is what the provider sees, finds, discovers which is where the dx is made. You could not code Asthma exacerbation with what you have stated as the exam
 
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