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alices

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Good morning everyone, if I have hx chronic back pain x20 years in the hpi but it is not in the pfsh fields can I still use it as such? or does it have to be in that field on the chart, our er charts is broken down in cc, hpi, ros, pfsh and exam formats..thank you. alice
 
Good Morning Alice,

The location of the documentation in the chart is unimportant. What you have to do is ascertain why the patient is there.

If he/she is there for back pain, it appears that x20 years reflects duration. If the patient is there for something else, it would seem to be reflective of a PMH. As it relates to utility of the same element (x20 years) as as two separate areas of history, some carriers have indicated that this is not permitted and that you may use it as one OR the other, giving you the discretion to decide here you put it.

I hope this helps!

Doris V. Branker, CPC, CPC-I, CEMC, CIRCC :)
 
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