Wiki How should i dx with no present signs and Symptoms

[m.matos@chcfl.com]

We have an issue were we have several patients come into the office with complaints of cough, runny nose, wheezing etc. The combination of symptoms will vary. These symptoms are indicated in the HPI. But in the ROS and the exam the pt is negative for everything and everything in the exam is clear. No runny nose, no cough, lungs are clear, no throat or ear irritations etc. The doctors are diagnosing these patients with a URI (upper respitory infection). In some cases they are prescribing antibiotics: is this correct? If the pt has no signs and symptoms should the provider code for a URI and be giving antibiotics? If this is not correct how should they code? And in other situations- no meds are given and the pt is just advised minor things like tylenol for fever, or saline and suction (but symptoms relating to these were not noted in the ROS or exam) and to return for worsening symptoms. Is this correct? We are having difficulty understanding how providers can dx a URI with no signs and symptoms.

 

[mitchellde]

as long as the providers progress note state URI then you can code it. If the provider gives the code but the note is absent the diagnosis then you cannot use the code for the URI. Infections the provider is allowed to diagnose using only what the patient presents with. While they be absent of symptoms during the exam, the patient relates having these then he uses the statements as an assist for the dx.

 

[jleu]

Signs and Symptoms, but ROS and Exam are "Normal"

If your providers are using an electronic health record to document their Evaluation and Management services, it is possible that they are "clicking through" or checking "All Normal" by mistake. You need to consider this possiblilty and make sure that your providers understand both how to document utilizing their electronic record system AND that they understand that they are creating, at the least, an incomplete record and possibly one with contradictions.