Wiki Question re: CC/HPI

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ahuffine

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I am doing some chart reviews and have a note where in the CC/HPI portion it says 'Unaware of the pink lesion on the upper back' (pt complained about something different on shoulder) which leads one to believe this was discovered during the examination and the dr asked the pt about it rather than the pt presenting with this concern as the CC. It was suggested I double check with AAPC: If during the exam a dr discovers something and asks the pt about it to obtain some history, does this count as CC / HPI?
 
My understanding regarding findings the provider discovers on exam is as follows:

If he only documents what he sees or feels (ie: "rough, scaley, pink lesion on upper back"), you cannot count this toward the HPI.

But if he asks the patient about it and documents the patient's answer ("pt says it has been present for several months and is asymptomatic"), the patient's reply can be counted in the HPI.
 
Ok, your example makes sense to me because the patient gave some information - thank you! So in my example I can count location and perhaps Quality (pink)?
 
No, if the provider found it on exam and just documented what he saw, then you can't get any HPI at all from it. The only HPI would be about the patient's complaint on the shoulder.
 
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