Patient has kidney stones and in the HPI physician says she does describe some urinary frequency, but drinks quite a bit of water throughout the day. Can I use some as severity?
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Tag Archives: Severity”
“moderate in severity” as HPI element
Can you count this statement (describing a skin lesion) toward the severity level in HPI? "It is moderate in severity." Or does the provider need to be more specific, like stating the size of the lesion, the pain (if any) it is causing, etc. (And if so, how do I know from a statement of the size of the lesion how severe this size is considered?)
Code to the “Highest Severity” for Drug Use, Abuse, and Dependence
When reporting a patient’s drug use, abuse, or dependence, ICD-10-CM guideline 5.C.2 states: Psychoactive Substance Use, Abuse And Dependence When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy: […]
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