tci ED Coding & Reimbursement Alert - 2013 Issue 7

Reader Question: Avoid Complaints From The Chief Over Your HPI Documentation

Question: Can I get others’ opinions on chief complaint and number of elements in this HPI? Per EMS, patient’s family called 911 because she has not been eating or drinking for the last week, worried that the patient may be dehydrated. Patient with known metastatic breast cancer having chosen to avoid aggressive treatment of same. Patient states she is in no pain, no nausea, thinks that he/she has been eating and drinking enough and not sure why family called 911. Pennsylvania Subscriber Answer: This is a difficult case because there does not appear to be a chief complaint...

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