Forum - Questions & Answers

Apr 20th, 2015 - MissDecember 5 

Credit or No credit for HPI - Modifying Factor

When a Physician asks the patient have you used any over the counter medication to help you with your rash? Patient states “no”. The Physician will include on documentation as follow:
Current Tx (treatment): None – see above – or list TX:
Previous Tx (treatment): None – or list Tx.
Note this is a standard question the Physician asks patient

In this case the Physician will state None for both current and previous treatments. I know this is a gray area when auditing. The Physician states this question is asked each time so patient can further be evaluated, to identify why the rash is irritated and or why it’s worse. Is this something you would give credit to the Physician? Could this be counted as modifying factor since patient is asked if currently or previously using any treatments? Please advise.

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