Wiki Using HPI for capturing diagnoses

[MichelleWerwinski]

Is this still a true statement? There is no rule or guideline that the diagnosis cannot be taken from the HPI or any other section of the documentation - only that the diagnosis must be documented "by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis)" as existing or affecting care at the time of the encounter. "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider." In the event that it is necessary to code symptoms, these in fact often are documented by the provider in the HPI.

 

[TThivierge]

Michelle
Yes, you need to follow your statement above. Use the dx code from the assessment or dx list given by provider. However if in documentation you get more details for medical coding then use it. For instance provider states patient has Pneumonia listing dx J12.9 but in provider s notations states patient has infection of Streph add dx B95 or dx J15.3 since more detail supported in documentation . Or let us say patient has UTI dx N39 but notice provider adds give patient meds due to lab result of certain bacteria from lab results. Or provider list as dx pain in ear but must read thru current record to see which ear has pain. Or patient has new fracture of right humerus, unspecified, provider might list S42.301A but as read documentation states it is Greenstick Fx. of right humerus = dx S42.311A. Hopefully the provider will give you date this happened, location (as examples park highway home),and how this happened (hit, crushed, in a fight, fell down steps,ETC )..You need this detail when coding fractures or any injuries. When have External dx codes use them on claim or payer will send it back for more data. Use most details given in documentation through out current record. Add in ancillary reports of lab & xrays done same day for assistance in detailed coding too

Here is a tip you can use the R code signs and symptoms but more detail use it to help selecting correct dx code. If provider mentions defined dx code..use that instead. Also try get sense of what provider is telling you in the patient's medical story. What I am speaking about is see following dx codes comparisons with info on the current situation.........

Diarrhea R19.7 vs Diarrhea K59.
Urgency of Urination R39.15 vs. N39.41 Urgency of Urination
Weakness R53.1 vs. Muscle Weakness M62 81 vs Age Related Weakness R54

I hope helped you a little bit. Also on coding Z codes some can come first and some should be last on claim.
Lady T