mnsmiller
New
Can the HPI be derived from the reason for surgery when the chief complaint of the visit is "surgical clearance"?
If the patient is sent to a cardiologist for pre-op clearance for an abnormal EKG and the physician obtains 4 HPI centered around the reason for the surgery, is this Ok? The surgery really prompted the visit. If the patient wasn't having surgery the cardiologist would not have seen him.
This seems to be a gray area and the only documentation I can find states that the HPI needs to be centered around the CC.
Thanks for any help that can be provided.
If the patient is sent to a cardiologist for pre-op clearance for an abnormal EKG and the physician obtains 4 HPI centered around the reason for the surgery, is this Ok? The surgery really prompted the visit. If the patient wasn't having surgery the cardiologist would not have seen him.
This seems to be a gray area and the only documentation I can find states that the HPI needs to be centered around the CC.
Thanks for any help that can be provided.