Christine Patterson
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Please advise me if I am wrong.
The physician noted in the HPI skin tag, but the diagnosis and in the procedure it was noted wart.
When auditing the encounter prior to finalization I queried the doctor on the HPI. The physician stated "that is what the patient said". I responded that I just wanted clarification so that I could make sure the correct procedure was inserted for billing purposes.
My question is am I correct that the chief complaint is what the patient thinks is wrong or dx. The HPI is the the physicians description meeting the standards with location, duration, quality etc.
Was I wrong to query the physician?
Thank you for your time and help in advance.
The physician noted in the HPI skin tag, but the diagnosis and in the procedure it was noted wart.
When auditing the encounter prior to finalization I queried the doctor on the HPI. The physician stated "that is what the patient said". I responded that I just wanted clarification so that I could make sure the correct procedure was inserted for billing purposes.
My question is am I correct that the chief complaint is what the patient thinks is wrong or dx. The HPI is the the physicians description meeting the standards with location, duration, quality etc.
Was I wrong to query the physician?
Thank you for your time and help in advance.