Forum - Questions & Answers
Linking the HPI to the A & P
Does each compliant in the HPI need a corresponding plan. For exampel, if HPI states patient presenting today for Hypertenstion and Hyperlipidemia and Osteoperiosis and the A& P only addresses hypertension and hyperlipdemia should the provider be requireed to go back and address the Osterperiosis?
re: Linking the HPI to the A & P
As a coder, I would hesitate to say that I "require" the provider to go back and document something.
Are you wondering whether to count it? That is a judgment call. If the information in the HPI is clear as to the status, I don't know of a rule in the Documentation Guidelines that doesn't let you "count" it. If it is a stable condition and didn't need a change in medications, it could be that the provided didn't need to mention it again.