The provider documented a chief complaint and a thorough HPI for a given problem. He also performed an exam for that problem. But he did not document any diagnosis or treatment for it. Instead, he apparently got distracted by a new problem he found on the exam, and dedicated the diagnosis and treatment portion of the note to the new problem.
So we have an HPI for problem #1 and a diagnosis and treatment plan for problem #2 (and an exam that relates to either or both).
Can we count the HPI points even though they don't relate to the diagnosis?
(I just want to clarify, in case the title of the post is misleading. It's not that the patient described the problem as something and the doctor diagnosed it as something else. It's that these are two unrelated problems.)
Last edited by CatchTheWind; Today at 10:35 AM.
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CC/HPI different from the visit's diagnosis